Provider Demographics
NPI:1902633514
Name:VACCINE PROVIDER LLC
Entity type:Organization
Organization Name:VACCINE PROVIDER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-367-2457
Mailing Address - Street 1:URB GOLDEN GATE II
Mailing Address - Street 2:P21 CALLE G
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725
Mailing Address - Country:US
Mailing Address - Phone:787-367-2457
Mailing Address - Fax:
Practice Address - Street 1:LIBERTY PLAZA CAYEY LOCAL #9
Practice Address - Street 2:
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736
Practice Address - Country:US
Practice Address - Phone:787-367-2457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service