Provider Demographics
NPI:1174079537
Name:PHM MULTIDISCIPLINARY CLINIC LLC
Entity type:Organization
Organization Name:PHM MULTIDISCIPLINARY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL AND HEALTH SERVICES DIRECTO
Authorized Official - Prefix:
Authorized Official - First Name:WALESKA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARRERO
Authorized Official - Suffix:
Authorized Official - Credentials:LCDA
Authorized Official - Phone:717-407-8764
Mailing Address - Street 1:1551 CALLE ALDA SUITE 201 URB. CARIBE
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-2709
Mailing Address - Country:US
Mailing Address - Phone:787-650-2732
Mailing Address - Fax:787-650-2734
Practice Address - Street 1:1551 CALLE ALDA
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-2709
Practice Address - Country:US
Practice Address - Phone:787-625-2500
Practice Address - Fax:787-625-0294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-26
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center