Provider Demographics
NPI:1548042872
Name:CENTRO QUIROPRACTICO DE VEGA ALTA LLC
Entity type:Organization
Organization Name:CENTRO QUIROPRACTICO DE VEGA ALTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:MAYSONET ACEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:787-994-9330
Mailing Address - Street 1:N11 CALLE 9
Mailing Address - Street 2:
Mailing Address - City:VEGA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00692-6010
Mailing Address - Country:US
Mailing Address - Phone:787-994-9330
Mailing Address - Fax:
Practice Address - Street 1:2 CALLE 1
Practice Address - Street 2:
Practice Address - City:VEGA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00692-7113
Practice Address - Country:US
Practice Address - Phone:787-245-4936
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-20
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR039624600Medicaid