Provider Demographics
NPI:1700624285
Name:CIDRA MONTANA LLC
Entity type:Organization
Organization Name:CIDRA MONTANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIEGO
Authorized Official - Middle Name:D
Authorized Official - Last Name:VARGAS GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-747-0022
Mailing Address - Street 1:PO BOX 2010
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-2010
Mailing Address - Country:US
Mailing Address - Phone:787-747-0022
Mailing Address - Fax:
Practice Address - Street 1:A12 CALLE CORCHADO, ESQ ANGEL L ORTIZ
Practice Address - Street 2:URB PARADISE
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00726
Practice Address - Country:US
Practice Address - Phone:787-747-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-18
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty