Healthcare Provider Details

I. General information

NPI: 1063771251
Provider Name (Legal Business Name): VITAL INC. CLINICA DE SALUD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAGUAS NORTE G 6 CALLE FLORENCIA
CAGUAS PR
00725
US

IV. Provider business mailing address

CAGUAS NORTE ST. FLORENCIA G 6
CAGUAS PR
00725
US

V. Phone/Fax

Practice location:
  • Phone: 787-258-5681
  • Fax: 787-258-5681
Mailing address:
  • Phone: 787-258-5681
  • Fax: 787-258-5681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number660749610
License Number StatePR

VIII. Authorized Official

Name: MRS. BETANIA REYES MATOS
Title or Position: M.D.
Credential: 16154
Phone: 787-258-5681