Provider Demographics
NPI:1346855863
Name:MADERA, VICTOR RAMON
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:RAMON
Last Name:MADERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB PARAISO DE MAYAGUEZ 191
Mailing Address - Street 2:CALLE SERENIDAD
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680
Mailing Address - Country:US
Mailing Address - Phone:787-649-7388
Mailing Address - Fax:
Practice Address - Street 1:AVENIDA RAMON ARBONA 1050
Practice Address - Street 2:BARRIO SABALOS
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-649-7388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR101310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility