Provider Demographics
NPI:1265869168
Name:WESTERN PR NEUROLOGICAL CLINIC CSP
Entity type:Organization
Organization Name:WESTERN PR NEUROLOGICAL CLINIC CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:ACEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-447-8819
Mailing Address - Street 1:#42 COSTA BRAVA STREET
Mailing Address - Street 2:URB. LAS VISTAS
Mailing Address - City:CABO ROJO
Mailing Address - State:PR
Mailing Address - Zip Code:00623
Mailing Address - Country:US
Mailing Address - Phone:787-265-6622
Mailing Address - Fax:787-265-6622
Practice Address - Street 1:MEDICAL EMPORIUM II CARR #2, NOSTOS AVENUE KY. 157
Practice Address - Street 2:SUITE 3A
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-265-6622
Practice Address - Fax:787-265-6622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16784261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty