1063686368 NPI number — JGM PSYCHIATRY SERVICES

Table of content: (NPI 1063686368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063686368 NPI number — JGM PSYCHIATRY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JGM PSYCHIATRY SERVICES
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:
N/A
Provider Other Organization Name Type Code:
3
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:
1063686368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
MENDEZ VIGO 63 E
Provider Second Line Business Mailing Address:
COND. CENTRO PLAZA OFIC. 5A
Provider Business Mailing Address City Name:
MAYAGUEZ
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00680
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-265-0370
Provider Business Mailing Address Fax Number:
787-265-0370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
COND MENDEZ VIGO W # 63E
Provider Second Line Business Practice Location Address:
COND. CENTRO PLAZA OFIC. 5A
Provider Business Practice Location Address City Name:
MAYAGUEZ
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00680-2800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-265-0370
Provider Business Practice Location Address Fax Number:
787-265-0370
Provider Enumeration Date:
04/17/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GAZTAMBIDE
Authorized Official First Name:
JAPHET
Authorized Official Middle Name:
Authorized Official Title or Position:
PSYCHIATRY
Authorized Official Telephone Number:
787-265-0370

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  11940 , 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)