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General NPI Number Information
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NPI Number | 1134650880
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Entity Type | Organization
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Legal Business Name | CLUB DEL DESARROLLO INTEGRAL, PSC
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Dates
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Enumeration Date | 03/24/2017
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Last Update Date | 03/24/2017
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Provider Practice Location Address
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Address Line | 110 CALLE CARAZO
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City | GUAYNABO
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State | PR
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Zip | 00969-5717
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Country | US
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Telephone | 787-790-1583
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Fax |
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Provider Business Mailing Address
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Address Line | 110 CALLE CARAZO
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City | GUAYNABO
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State | PR
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Zip | 00969-5717
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Country | US
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Telephone | 787-790-1583
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. RAUL RIVERA VEGA
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Credential |
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Telephone | 787-790-1583
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 1361
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License Number State | PR
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 1008
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License Number State | PR
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