Provider Demographics
NPI:1477140655
Name:PERFORMANCE SPORTS MED LLC
Entity Type:Organization
Organization Name:PERFORMANCE SPORTS MED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEJANDRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GONZALEZ VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-831-5831
Mailing Address - Street 1:PO BOX 631
Mailing Address - Street 2:
Mailing Address - City:CABO ROJO
Mailing Address - State:PR
Mailing Address - Zip Code:00623-0631
Mailing Address - Country:US
Mailing Address - Phone:787-831-5831
Mailing Address - Fax:
Practice Address - Street 1:60 CALLE RMN BTNCES N STE 207
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-6695
Practice Address - Country:US
Practice Address - Phone:787-831-5831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty