Provider Demographics
NPI:1003254582
Name:CENTRO DE VACUNACION VEGA BAJA
Entity Type:Organization
Organization Name:CENTRO DE VACUNACION VEGA BAJA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CEREZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-855-0031
Mailing Address - Street 1:52 CALLE PALMER
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-2428
Mailing Address - Country:US
Mailing Address - Phone:787-855-0031
Mailing Address - Fax:
Practice Address - Street 1:2 AVE. #107 OFFICE, WILMA N. VAZQUEZ
Practice Address - Street 2:
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693
Practice Address - Country:US
Practice Address - Phone:787-855-0031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9816261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR82133PRMedicare PIN
PRE81957Medicare UPIN