Healthcare Provider Details

I. General information

NPI: 1700624285
Provider Name (Legal Business Name): CIDRA MONTANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

A12 CALLE CORCHADO, ESQ ANGEL L ORTIZ URB PARADISE
CAGUAS PR
00726
US

IV. Provider business mailing address

PO BOX 2010
CAGUAS PR
00726-2010
US

V. Phone/Fax

Practice location:
  • Phone: 787-747-0022
  • Fax:
Mailing address:
  • Phone: 787-747-0022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DIEGO D VARGAS GONZALEZ
Title or Position: PRESIDENT
Credential:
Phone: 787-747-0022