Healthcare Provider Details

I. General information

NPI: 1477140655
Provider Name (Legal Business Name): PERFORMANCE SPORTS MED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2020
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 CALLE RMN BTNCES N STE 207
MAYAGUEZ PR
00680-6695
US

IV. Provider business mailing address

PO BOX 631
CABO ROJO PR
00623-0631
US

V. Phone/Fax

Practice location:
  • Phone: 787-831-5831
  • Fax:
Mailing address:
  • Phone: 787-831-5831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ALEJANDRA E GONZALEZ VEGA
Title or Position: PRESIDENT
Credential: MD
Phone: 787-831-5831