1154535243 NPI number — VICTOR M VEGA

Table of content: (NPI 1154535243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154535243 NPI number — VICTOR M VEGA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTOR M VEGA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154535243
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
535 CALLE JUAN RODRIGUEZ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENUELAS
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00624-1804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-585-3324
Provider Business Mailing Address Fax Number:
787-259-3292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CARR 385, KM. 0.5, BO. CUEVAS
Provider Second Line Business Practice Location Address:
CDT DE PENUELAS
Provider Business Practice Location Address City Name:
PENUELAS
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-585-3324
Provider Business Practice Location Address Fax Number:
787-259-3292
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VEGA
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
787-585-3324

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  P1772 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: TC AMB 450 . This is a "COMISION SERVICIO PUBLICO" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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