Provider Demographics
NPI:1205187697
Name:BELLA VISTA POLICLINIC, INC
Entity Type:Organization
Organization Name:BELLA VISTA POLICLINIC, INC
Other - Org Name:BELLA VISTA ENT GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:787-652-6031
Mailing Address - Street 1:AVE HOSTOS
Mailing Address - Street 2:NUMBER 770
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681
Mailing Address - Country:US
Mailing Address - Phone:787-652-6031
Mailing Address - Fax:787-805-3705
Practice Address - Street 1:AVE HOSTOS
Practice Address - Street 2:NUMBER 770
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00681
Practice Address - Country:US
Practice Address - Phone:787-652-6031
Practice Address - Fax:787-805-3705
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BELLA VISTA POLICLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR200394261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR28395Medicare PIN