Healthcare Provider Details

I. General information

NPI: 1215273636
Provider Name (Legal Business Name): CLINICA PODIATRICA AVILES, CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2012
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2431 AVE LAS AMERICAS EDIFICIO PORRATA PILA SUITE 208
PONCE PR
00717
US

IV. Provider business mailing address

PO BOX 986
LAJAS PR
00667-0986
US

V. Phone/Fax

Practice location:
  • Phone: 939-292-4627
  • Fax:
Mailing address:
  • Phone: 939-292-4627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number109
License Number StatePR

VIII. Authorized Official

Name: HILDA J AVILES-VARGAS
Title or Position: PRESIDENT
Credential: DPM
Phone: 939-292-4627