Provider Demographics
NPI:1578904082
Name:PEDIATRIA BUENA VISTA CSP
Entity Type:Organization
Organization Name:PEDIATRIA BUENA VISTA CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-799-9977
Mailing Address - Street 1:URB TINTILLO GARDENS
Mailing Address - Street 2:CALLE 1 B 5
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-1666
Mailing Address - Country:US
Mailing Address - Phone:787-799-9977
Mailing Address - Fax:
Practice Address - Street 1:CARR 167
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-4477
Practice Address - Country:US
Practice Address - Phone:787-799-9977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14533261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service