Provider Demographics
NPI:1740040575
Name:PURA VITA
Entity type:Organization
Organization Name:PURA VITA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYNE
Authorized Official - Middle Name:F
Authorized Official - Last Name:DELGADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-356-2384
Mailing Address - Street 1:57 CALLE LAURELES
Mailing Address - Street 2:
Mailing Address - City:CAMUY
Mailing Address - State:PR
Mailing Address - Zip Code:00627-9554
Mailing Address - Country:US
Mailing Address - Phone:787-356-2384
Mailing Address - Fax:
Practice Address - Street 1:109 AVE DR SUSONI
Practice Address - Street 2:
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659-1955
Practice Address - Country:US
Practice Address - Phone:787-356-2384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-20
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service