Provider Demographics
NPI:1144514951
Name:BELLA VISTA POLICLINIC INC
Entity type:Organization
Organization Name:BELLA VISTA POLICLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:787-834-6000
Mailing Address - Street 1:AVE HOSTOS
Mailing Address - Street 2:NUMBER 770
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00682-6353
Mailing Address - Country:US
Mailing Address - Phone:787-834-6161
Mailing Address - Fax:787-834-4635
Practice Address - Street 1:AVE HOSTOS
Practice Address - Street 2:NUMBER 770
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00682-6353
Practice Address - Country:US
Practice Address - Phone:787-834-6161
Practice Address - Fax:787-834-4635
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BELLA VISTA POLICLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR200394261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR28395Medicare PIN