Provider Demographics
NPI:1922787621
Name:VIDASANA FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:VIDASANA FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:LOPEZ PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-515-7316
Mailing Address - Street 1:592 CALLE CESAR GONZALEZ APT 711
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-3957
Mailing Address - Country:US
Mailing Address - Phone:787-515-7316
Mailing Address - Fax:
Practice Address - Street 1:592 CALLE CESAR GONZALEZ APT 711
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3957
Practice Address - Country:US
Practice Address - Phone:787-515-7316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty