Provider Demographics
NPI:1073786547
Name:LA VIDA MEDICAL GROUP HATILLO PT
Entity Type:Organization
Organization Name:LA VIDA MEDICAL GROUP HATILLO PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:I
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-878-8155
Mailing Address - Street 1:549 CALLE DEL MAR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:HATILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00659-2869
Mailing Address - Country:US
Mailing Address - Phone:787-878-8802
Mailing Address - Fax:787-881-4312
Practice Address - Street 1:549 CALLE DEL MAR
Practice Address - Street 2:SUITE 304
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659-2869
Practice Address - Country:US
Practice Address - Phone:787-878-8802
Practice Address - Fax:787-881-4312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR707208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR80310Medicare PIN