1063803187 NPI number — INTEGRATED MENTAL HEALTH GROUP

Table of content: (NPI 1063803187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063803187 NPI number — INTEGRATED MENTAL HEALTH GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED MENTAL HEALTH GROUP
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:
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:
1063803187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
530 CAMINO LOS AQUINOS
Provider Second Line Business Mailing Address:
APARTAMENTO 178
Provider Business Mailing Address City Name:
TRUJILLO ALTO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00976-7901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-462-0969
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CARRETERA 693 KM 13.8 EDIFICIO BRISAS DEL MAR
Provider Second Line Business Practice Location Address:
BO SABANA
Provider Business Practice Location Address City Name:
VEGA ALTA
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00692
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-604-0186
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/11/2015

Additional Information

Authorized Official

Authorized Official Last Name:
RIVERA
Authorized Official First Name:
GERARDO
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENTE
Authorized Official Telephone Number:
787-462-0969

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  2797 , 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)





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