Provider Demographics
NPI:1679876718
Name:GALENOS SELECTOS DE PUERTO RICO, INC.
Entity type:Organization
Organization Name:GALENOS SELECTOS DE PUERTO RICO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EFRAIN
Authorized Official - Middle Name:DIEGO
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-990-4204
Mailing Address - Street 1:PMB 261 BOX 7105
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00732
Mailing Address - Country:UM
Mailing Address - Phone:787-284-1566
Mailing Address - Fax:787-290-6689
Practice Address - Street 1:PLAZOLETA PONCE CASH AND CARRY MORELL CAMPOS
Practice Address - Street 2:LOCAL 4
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00732
Practice Address - Country:US
Practice Address - Phone:787-284-1566
Practice Address - Fax:787-290-6689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11B2134261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center