Provider Demographics
NPI:1194598623
Name:P.R. MED VITALITY LLC
Entity type:Organization
Organization Name:P.R. MED VITALITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SURIS CANCEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:939-299-0113
Mailing Address - Street 1:URBANIZACION REMANSO CALLE BAYA HONDA 1020
Mailing Address - Street 2:
Mailing Address - City:CABO ROJO
Mailing Address - State:PR
Mailing Address - Zip Code:00623
Mailing Address - Country:US
Mailing Address - Phone:939-299-0112
Mailing Address - Fax:
Practice Address - Street 1:3 CALLE JARDINES
Practice Address - Street 2:
Practice Address - City:HORMIGUEROS
Practice Address - State:PR
Practice Address - Zip Code:00660-1733
Practice Address - Country:US
Practice Address - Phone:939-299-0112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty