Provider Demographics
NPI:1801967815
Name:CLINICA CIRUGIA AMBULATORIA DR. LUIS A. VAZQUEZ, INC
Entity type:Organization
Organization Name:CLINICA CIRUGIA AMBULATORIA DR. LUIS A. VAZQUEZ, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEVES ROSAIO
Authorized Official - Suffix:
Authorized Official - Credentials:MSHA MBA
Authorized Official - Phone:787-833-4400
Mailing Address - Street 1:PO BOX 3748
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-3748
Mailing Address - Country:US
Mailing Address - Phone:787-833-4400
Mailing Address - Fax:787-265-6621
Practice Address - Street 1:CALLE PERAL ESQ DE DIEGO
Practice Address - Street 2:EDIFICIO LA PALMA PISO 6
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-833-4400
Practice Address - Fax:787-265-6621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-06-22
Deactivation Date:2020-04-29
Deactivation Code:
Reactivation Date:2020-06-22
Provider Licenses
StateLicense IDTaxonomies
PR745291U00000X
PR87261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
10235Medicare PIN