Provider Demographics
NPI:1518175322
Name:GRUPO FISIATRICO VILLA CARMEN, CSP
Entity Type:Organization
Organization Name:GRUPO FISIATRICO VILLA CARMEN, CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LIMARY
Authorized Official - Middle Name:RIOS
Authorized Official - Last Name:CAMACHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-743-8730
Mailing Address - Street 1:PO BOX 9328
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-9328
Mailing Address - Country:US
Mailing Address - Phone:787-743-8730
Mailing Address - Fax:787-745-6133
Practice Address - Street 1:BAYAMON K 13
Practice Address - Street 2:VILLA CARMEN
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-743-8730
Practice Address - Fax:787-745-6133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12556174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG78953Medicare UPIN
PR0089794Medicare ID - Type UnspecifiedPROVIDER NUMBER