Provider Demographics
NPI:1114319183
Name:VASCULAR DIAGNOSTIC GROUP CORP PSC
Entity Type:Organization
Organization Name:VASCULAR DIAGNOSTIC GROUP CORP PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-210-8795
Mailing Address - Street 1:RES VILLA DEL REY # 3
Mailing Address - Street 2:SABOYA A4
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-7113
Mailing Address - Country:US
Mailing Address - Phone:787-210-8795
Mailing Address - Fax:787-258-5487
Practice Address - Street 1:RES VILLA DEL REY # 3
Practice Address - Street 2:SABOYA A4
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-7113
Practice Address - Country:US
Practice Address - Phone:787-210-8795
Practice Address - Fax:787-258-5487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory