Provider Demographics
NPI:1821374661
Name:PRUDENTIAL HEALTH NETWORK
Entity Type:Organization
Organization Name:PRUDENTIAL HEALTH NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VLADIMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-915-3030
Mailing Address - Street 1:PO BOX 1652
Mailing Address - Street 2:
Mailing Address - City:VEGA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00692-1652
Mailing Address - Country:US
Mailing Address - Phone:787-915-3030
Mailing Address - Fax:787-915-3033
Practice Address - Street 1:CARR #2 KM 29.7
Practice Address - Street 2:
Practice Address - City:VEGA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00692
Practice Address - Country:US
Practice Address - Phone:787-915-3030
Practice Address - Fax:787-915-3033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization