Healthcare Provider Details

I. General information

NPI: 1497195879
Provider Name (Legal Business Name): FERNANDO VIEJO 333
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 06/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

C MARTE 126 ATLANTIS VIEW ISLA VERDE
CAROLINA PR
00982-0982
US

IV. Provider business mailing address

C MARTE 126 ATLANTIS VIEW ISLA VERDE
CAROLINA PR
00979
US

V. Phone/Fax

Practice location:
  • Phone: 787-644-3889
  • Fax: 787-268-2787
Mailing address:
  • Phone: 787-644-3889
  • Fax: 787-268-2787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number333
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code174MM1900X
TaxonomyMedical Research Veterinarian
License Number33
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: