Provider Demographics
NPI:1831450717
Name:VIDA PLUS MEDICAL CLINIC, CSP
Entity type:Organization
Organization Name:VIDA PLUS MEDICAL CLINIC, CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:CAMPOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-731-4949
Mailing Address - Street 1:AVE. FCO. CORRETJER NARVAEZ, LOTE 21, CALLE E,
Mailing Address - Street 2:EDF. CARIBBEAN CINEMAS, SUITE 201
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970
Mailing Address - Country:US
Mailing Address - Phone:787-731-4949
Mailing Address - Fax:
Practice Address - Street 1:AVE. FCO. CORRETJER NARVAEZ, LOTE 21, CALLE E,
Practice Address - Street 2:EDF. CARIBBEAN CINEMAS, SUITE 201
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00970-3925
Practice Address - Country:US
Practice Address - Phone:787-731-4949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13839302R00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0021499OtherPTAN