MEDICARE: CENTRO DE VIDA QUIROPRACTICA CSP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	472	PR

General Provider Information

NPI Number	:	1194011809
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO DE VIDA QUIROPRACTICA CSP

Provider Business Mailing Address
First Line	:	R9 AVE LUIS MUNOZ MARIN
Second Line	:
City	:	CAGUAS
State	:	PR
Zip	:	00725-6461
Country	:	US
Telephone Number	:	619-252-4572
Fax Number	:	787-961-5656

Provider Business Practice Location Address
First Line	:	R9 AVE LUIS MUNOZ MARIN URB MARIOLGA
Second Line	:
City	:	CAGUAS
State	:	PR
Zip	:	00725
Country	:	US
Telephone Number	:	619-252-4572
Fax Number	:	787-961-5656

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EVA E SEPULVEDA TORRES
Credential	:	DC
Telephone Number	:	619-252-4572

Provider Enumeration Date	:	06/21/2011
Last Update Date	:	06/21/2011

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