Provider Demographics
NPI:1174954507
Name:PREVENTIVE FAMILY MEDICINE PSC
Entity type:Organization
Organization Name:PREVENTIVE FAMILY MEDICINE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:P
Authorized Official - Last Name:LAGRANDIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-531-2123
Mailing Address - Street 1:200 AVE RAFAEL CORDERO
Mailing Address - Street 2:SUITE 140 PMB 509
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-3740
Mailing Address - Country:US
Mailing Address - Phone:787-531-2123
Mailing Address - Fax:
Practice Address - Street 1:200 AVE RAFAEL CORDERO
Practice Address - Street 2:SUITE 140 PMB 509
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-3740
Practice Address - Country:US
Practice Address - Phone:787-531-2123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16068207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty