Healthcare Provider Details

I. General information

NPI: 1134650880
Provider Name (Legal Business Name): CLUB DEL DESARROLLO INTEGRAL, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CALLE CARAZO
GUAYNABO PR
00969-5717
US

IV. Provider business mailing address

110 CALLE CARAZO
GUAYNABO PR
00969-5717
US

V. Phone/Fax

Practice location:
  • Phone: 787-790-1583
  • Fax:
Mailing address:
  • Phone: 787-790-1583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number1008
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1361
License Number StatePR

VIII. Authorized Official

Name: MR. RAUL RIVERA VEGA
Title or Position: PRESIDENT
Credential:
Phone: 787-790-1583