Healthcare Provider Details

I. General information

NPI: 1891682316
Provider Name (Legal Business Name): PERFORMANCE SPORTS MED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2025
Last Update Date: 06/18/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 AVE HOSTOS SUITE 206
MAYAGUEZ PR
00680
US

IV. Provider business mailing address

351 AVE HOSTOS SUITE 206
MAYAGUEZ PR
00680
US

V. Phone/Fax

Practice location:
  • Phone: 787-831-5831
  • Fax: 787-827-8020
Mailing address:
  • Phone: 787-831-5831
  • Fax: 787-827-8020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ALEJANDRA E GONZALEZ VEGA
Title or Position: PRESIDENT
Credential: M.D., CAQSM
Phone: 787-404-0909