Healthcare Provider Details

I. General information

NPI: 1316163843
Provider Name (Legal Business Name): CENTRO DE VACUNACION DEL NOROESTE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LIRIO F-3 BZN.27 URB. VISTAS DE SAN LOENZO
SAN LORENZO PR
00754
US

IV. Provider business mailing address

PO BOX 7003 CAGUAS
CAGUAS PR
00726-7003
US

V. Phone/Fax

Practice location:
  • Phone: 787-736-7539
  • Fax: 787-736-7539
Mailing address:
  • Phone: 787-736-7539
  • Fax: 787-736-7539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number1134
License Number StatePR

VIII. Authorized Official

Name: MR. FUAD S. ALBA
Title or Position: PRESIDENTE
Credential:
Phone: 787-736-7539