Provider Demographics
NPI:1811249840
Name:CENTRO CLINICO DE VEGA ALTA CORP
Entity type:Organization
Organization Name:CENTRO CLINICO DE VEGA ALTA CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARITZA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRINIDAD REYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-617-6141
Mailing Address - Street 1:138 WINSTON CHURCHILL AVENUE
Mailing Address - Street 2:EL SENORIAL MAIL STATION 641
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-883-5917
Mailing Address - Fax:
Practice Address - Street 1:CALLE MUNOZ RIVERA NUM 5A
Practice Address - Street 2:
Practice Address - City:VEGA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00692
Practice Address - Country:US
Practice Address - Phone:787-883-5917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-15
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty