Provider Demographics
NPI:1184708448
Name:CENTRO MEDICINA PRIMARIA VEGA ALTA
Entity type:Organization
Organization Name:CENTRO MEDICINA PRIMARIA VEGA ALTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MILDALIAS
Authorized Official - Middle Name:DOMINGUEZ
Authorized Official - Last Name:PASCUAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-883-0124
Mailing Address - Street 1:P.O. BOX 4317
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00694-4317
Mailing Address - Country:US
Mailing Address - Phone:787-883-0124
Mailing Address - Fax:787-883-7645
Practice Address - Street 1:CARR 2 KM 31.9
Practice Address - Street 2:BO. BAJURA
Practice Address - City:VEGA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00692
Practice Address - Country:US
Practice Address - Phone:787-883-0124
Practice Address - Fax:787-883-7645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR19197OtherTRIPLE S