Healthcare Provider Details

I. General information

NPI: 1043700743
Provider Name (Legal Business Name): MEDIVIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407B CALLE JUAN A DAVILA SUITE 2
SAN JUAN PR
00918
US

IV. Provider business mailing address

PO BOX 16474
SAN JUAN PR
00908-6474
US

V. Phone/Fax

Practice location:
  • Phone: 787-504-5005
  • Fax:
Mailing address:
  • Phone: 787-396-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HEILEENE TORRES COLBERG
Title or Position: PARTNER
Credential:
Phone: 787-396-5050