Provider Demographics
NPI:1164276929
Name:GERIVITALITY HOLDINGS LLC
Entity Type:Organization
Organization Name:GERIVITALITY HOLDINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FAUDES
Authorized Official - Middle Name:ILEANA
Authorized Official - Last Name:LUGO MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-314-8430
Mailing Address - Street 1:PO BOX 560
Mailing Address - Street 2:
Mailing Address - City:LAJAS
Mailing Address - State:PR
Mailing Address - Zip Code:00667-0560
Mailing Address - Country:US
Mailing Address - Phone:787-314-8430
Mailing Address - Fax:
Practice Address - Street 1:38 CALLE AMISTAD STE 2B
Practice Address - Street 2:
Practice Address - City:LAJAS
Practice Address - State:PR
Practice Address - Zip Code:00667-2072
Practice Address - Country:US
Practice Address - Phone:787-314-8430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty