Healthcare Provider Details

I. General information

NPI: 1073167771
Provider Name (Legal Business Name): CLINICA VITALIZA CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2019
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAROLINA SHOPPING COURT 307A AVENIDA ROBERTO CLEMENTE
CAROLINA PR
00985
US

IV. Provider business mailing address

URB VILLA CAROLINA 141-15 CALLE 411
CAROLINA PR
00985
US

V. Phone/Fax

Practice location:
  • Phone: 787-627-9285
  • Fax:
Mailing address:
  • Phone: 787-627-9285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JOHARYS K AYBAR CRUZ
Title or Position: PRESIDENTE
Credential:
Phone: 787-627-9285