Provider Demographics
NPI:1043246788
Name:BELLA VISTA POLICLINIC, INC
Entity Type:Organization
Organization Name:BELLA VISTA POLICLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-834-6161
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-0850
Mailing Address - Country:US
Mailing Address - Phone:787-834-6161
Mailing Address - Fax:787-805-4635
Practice Address - Street 1:AVE HOSTOS
Practice Address - Street 2:NUMBER 770
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00682-6353
Practice Address - Country:US
Practice Address - Phone:787-834-6161
Practice Address - Fax:787-805-4635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10 CNC 99-331261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR28395Medicare ID - Type UnspecifiedRADIOLOGY
PR38325Medicare ID - Type UnspecifiedLABORATORY