Provider Demographics
NPI:1811178551
Name:UNIVERSITY OF PUERTO RICO-RIO PIEDRAS CAMPUS
Entity type:Organization
Organization Name:UNIVERSITY OF PUERTO RICO-RIO PIEDRAS CAMPUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:787-764-0000
Mailing Address - Street 1:PO BOX 23307
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00931-3307
Mailing Address - Country:US
Mailing Address - Phone:787-764-0000
Mailing Address - Fax:787-764-3825
Practice Address - Street 1:AVE. PONCE DE LEON PDA. 39.5
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00931-3307
Practice Address - Country:US
Practice Address - Phone:787-764-0000
Practice Address - Fax:787-764-3825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care