Healthcare Provider Details

I. General information

NPI: 1801967815
Provider Name (Legal Business Name): CLINICA CIRUGIA AMBULATORIA DR. LUIS A. VAZQUEZ, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date: 04/29/2020
Reactivation Date: 06/22/2020

III. Provider practice location address

CALLE PERAL ESQ DE DIEGO EDIFICIO LA PALMA PISO 6
MAYAGUEZ PR
00680
US

IV. Provider business mailing address

PO BOX 3748
MAYAGUEZ PR
00681-3748
US

V. Phone/Fax

Practice location:
  • Phone: 787-833-4400
  • Fax: 787-265-6621
Mailing address:
  • Phone: 787-833-4400
  • Fax: 787-265-6621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number87
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number745
License Number StatePR

VIII. Authorized Official

Name: MR. JESUS NIEVES ROSAIO
Title or Position: ADMINISTRATOR
Credential: MSHA MBA
Phone: 787-833-4400