Provider Demographics
NPI:1578821542
Name:PROHEALTH THERAPY & SPORTS REHAB, PSC
Entity Type:Organization
Organization Name:PROHEALTH THERAPY & SPORTS REHAB, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENIFFER
Authorized Official - Middle Name:MARI
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-313-0829
Mailing Address - Street 1:HC 03 BOX 29780
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-9305
Mailing Address - Country:US
Mailing Address - Phone:787-313-0829
Mailing Address - Fax:787-200-8030
Practice Address - Street 1:BO GUAYABO CARR 115
Practice Address - Street 2:KM 20.6
Practice Address - City:AGUADA
Practice Address - State:PR
Practice Address - Zip Code:00602-9305
Practice Address - Country:US
Practice Address - Phone:787-313-0829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1374261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1374OtherPROVIDER LICENSE
PR1053516252OtherINDIVIDUAL NPI
PR1053516252OtherINDIVIDUAL NPI