Healthcare Provider Details

I. General information

NPI: 1649659756
Provider Name (Legal Business Name): PUERTO RICO VASCULAR ACCESS CENTER PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2015
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE PONCE DE LEON PDA 37 1/2 HOSP AUXILIO MUTUO 1ST FL
SAN JUAN PR
00918-1227
US

IV. Provider business mailing address

PO BOX 361275
SAN JUAN PR
00936-1275
US

V. Phone/Fax

Practice location:
  • Phone: 787-758-3320
  • Fax: 787-758-3358
Mailing address:
  • Phone: 787-758-3320
  • Fax: 787-758-3358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CARLOS G RIVERA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-361-0012