Healthcare Provider Details

I. General information

NPI: 1548165806
Provider Name (Legal Business Name): JOSE HIRAM VIDAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 AVENIDA TITO CASTRO UNIT 113
PONCE PR
00716
US

IV. Provider business mailing address

PARC NUEVA VIDA CALLE RAFAEL RODRIGUEZ Q140 #2
PONCE PR
00728
US

V. Phone/Fax

Practice location:
  • Phone: 787-221-3978
  • Fax:
Mailing address:
  • Phone: 787-221-3978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number001214
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: