Provider Demographics
NPI:1366060766
Name:PREPVEN CORP
Entity type:Organization
Organization Name:PREPVEN CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLAZO PAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-918-8618
Mailing Address - Street 1:315 AVE MANUEL DOMENECH STE 1
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-3513
Mailing Address - Country:US
Mailing Address - Phone:787-918-8618
Mailing Address - Fax:
Practice Address - Street 1:315 CALLE MANUEL DOMENECH STE 1
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3513
Practice Address - Country:US
Practice Address - Phone:787-918-8618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-12
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR039197200Medicaid