Healthcare Provider Details

I. General information

NPI: 1407222482
Provider Name (Legal Business Name): JEFFREY CANDELARIO -VIDRO SR. R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2015
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

APS PUERTO RICO, AVE. HOSTOS OFFICE PARK 2, MEDICAL EMPORIUM, PISO 4, SUITE 406
MAYAGUEZ PUERTO RICO
00680
UM

IV. Provider business mailing address

HC 9 BOX 4059
SABANA GRANDE PR
00637-9426
US

V. Phone/Fax

Practice location:
  • Phone: 787-641-0773
  • Fax:
Mailing address:
  • Phone: 787-910-8329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number15327
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: