Provider Demographics
NPI:1255788386
Name:BALANCE AND VESTIBULAR REHAB, LLC
Entity type:Organization
Organization Name:BALANCE AND VESTIBULAR REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIMARIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:787-552-9757
Mailing Address - Street 1:L26 CALLE 14
Mailing Address - Street 2:EL CONQUISTADOR
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-6426
Mailing Address - Country:US
Mailing Address - Phone:787-552-9757
Mailing Address - Fax:
Practice Address - Street 1:CARR. 8860 KM 1.5
Practice Address - Street 2:PLAZA MATIENZO
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976-6426
Practice Address - Country:US
Practice Address - Phone:787-552-9757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1431225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR511526117516-001OtherCCN MEDICARE