Provider Demographics
NPI:1033316856
Name:LA VIDA MEDICAL GROUP HATILLO CORP
Entity type:Organization
Organization Name:LA VIDA MEDICAL GROUP HATILLO CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:I
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-880-2363
Mailing Address - Street 1:549 CALLE DEL MAR
Mailing Address - Street 2:SUITE 302
Mailing Address - City:HATILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00659-2869
Mailing Address - Country:US
Mailing Address - Phone:787-880-2363
Mailing Address - Fax:787-881-4312
Practice Address - Street 1:549 CALLE DEL MAR
Practice Address - Street 2:SUITE 302
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659-2869
Practice Address - Country:US
Practice Address - Phone:787-880-2363
Practice Address - Fax:787-881-4312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC0700X, 207R00000X, 207RP1001X, 208100000X, 261QR0206X, 207Q00000X
PR13836208D00000X
PR000085213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, MammographyGroup - Multi-Specialty