1164754826 NPI number — MARIO LUIS PEREZ RODRIGUEZ PSYCHOLOGIST

Table of content: MARIO LUIS PEREZ RODRIGUEZ PSYCHOLOGIST (NPI 1164754826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164754826 NPI number — MARIO LUIS PEREZ RODRIGUEZ PSYCHOLOGIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEREZ RODRIGUEZ
Provider First Name:
MARIO
Provider Middle Name:
LUIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYCHOLOGIST
Provider Gender Code:
M

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:
1164754826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
URB.VEREDAS
Provider Second Line Business Mailing Address:
#389
Provider Business Mailing Address City Name:
GURABO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-453-6132
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MED WELLNESS CLINIC
Provider Second Line Business Practice Location Address:
PD PLAZA LOCAL 3
Provider Business Practice Location Address City Name:
CAGUAS
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-453-6132
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  3627 , 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)

  • Identifier: 3627 . This is a "LISENCE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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