Provider Demographics
NPI:1134650880
Name:CLUB DEL DESARROLLO INTEGRAL, PSC
Entity Type:Organization
Organization Name:CLUB DEL DESARROLLO INTEGRAL, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-790-1583
Mailing Address - Street 1:110 CALLE CARAZO
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969-5717
Mailing Address - Country:US
Mailing Address - Phone:787-790-1583
Mailing Address - Fax:
Practice Address - Street 1:110 CALLE CARAZO
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969-5717
Practice Address - Country:US
Practice Address - Phone:787-790-1583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1008261QM1300X
PR1361261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy