Provider Demographics
NPI:1053082891
Name:CLINICA REUVIVA
Entity Type:Organization
Organization Name:CLINICA REUVIVA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRADORA
Authorized Official - Prefix:MS
Authorized Official - First Name:ISIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:VAZQUEZ-OTERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:939-945-8335
Mailing Address - Street 1:55 CALLE CASALS
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969-1004
Mailing Address - Country:US
Mailing Address - Phone:939-945-8335
Mailing Address - Fax:
Practice Address - Street 1:1 AVE ALBOLOTE STE 201
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969-2807
Practice Address - Country:US
Practice Address - Phone:939-945-8335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1270055-0014OtherCERT REGISTRO DE COMERCIANTE