Healthcare Provider Details

I. General information

NPI: 1831450717
Provider Name (Legal Business Name): VIDA PLUS MEDICAL CLINIC, CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 02/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE. FCO. CORRETJER NARVAEZ, LOTE 21, CALLE E, EDF. CARIBBEAN CINEMAS, SUITE 201
GUAYNABO PR
00970-3925
US

IV. Provider business mailing address

AVE. FCO. CORRETJER NARVAEZ, LOTE 21, CALLE E, EDF. CARIBBEAN CINEMAS, SUITE 201
GUAYNABO PR
00970
US

V. Phone/Fax

Practice location:
  • Phone: 787-731-4949
  • Fax:
Mailing address:
  • Phone: 787-731-4949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number13839
License Number StatePR

VIII. Authorized Official

Name: DR. JOSEPH S. CAMPOS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-731-4949