=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134308398
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRO PEDIATRICO BUENA VISTA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2007
-----------------------------------------------------
Last Update Date | 10/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 167 # KM14.8 BO. BUENA VISTA
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00956-9212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-799-9977
-----------------------------------------------------
Fax | 787-799-9977
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | KK-7 CALLE 10 URB CANA
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00957-6232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-799-9977
-----------------------------------------------------
Fax | 787-799-9977
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. GISSELLE CASTRO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-799-9977
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------