Healthcare Provider Details

I. General information

NPI: 1033316856
Provider Name (Legal Business Name): LA VIDA MEDICAL GROUP HATILLO CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 CALLE DEL MAR SUITE 302
HATILLO PR
00659-2869
US

IV. Provider business mailing address

549 CALLE DEL MAR SUITE 302
HATILLO PR
00659-2869
US

V. Phone/Fax

Practice location:
  • Phone: 787-880-2363
  • Fax: 787-881-4312
Mailing address:
  • Phone: 787-880-2363
  • Fax: 787-881-4312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number13836
License Number StatePR
# 6
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000085
License Number StatePR
# 7
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DIANA I MATOS
Title or Position: BILLING MANAGER
Credential:
Phone: 787-880-2363