Provider Demographics
NPI:1083150262
Name:HOGAR LUZ DE VIDA INC
Entity Type:Organization
Organization Name:HOGAR LUZ DE VIDA INC
Other - Org Name:HOGAR LUZ DE VIDA
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:ORLANDO
Authorized Official - Last Name:PEREZ-RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-410-0781
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-0219
Mailing Address - Country:US
Mailing Address - Phone:787-833-1508
Mailing Address - Fax:
Practice Address - Street 1:CARR 108 KM 10.9 RAMAL 4430 INTERIOR
Practice Address - Street 2:BO LEQUISAMO
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00681
Practice Address - Country:US
Practice Address - Phone:787-833-1508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0348324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility