1255749396 NPI number — T&C MENTAL HEALTH HOME SERVICE, INC

Table of content: JUAN CARLOS PORTELA DMD (NPI 1952599649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255749396 NPI number — T&C MENTAL HEALTH HOME SERVICE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
T&C MENTAL HEALTH HOME SERVICE, INC
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:
1255749396
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
SENDEROS DEL RIO 860
Provider Second Line Business Mailing Address:
CARR.175 APT. 1406
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-614-3006
Provider Business Mailing Address Fax Number:
787-545-2543

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SENDEROS DEL RIO 860
Provider Second Line Business Practice Location Address:
CARR.175 APT. 1406
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-614-3006
Provider Business Practice Location Address Fax Number:
787-545-2543
Provider Enumeration Date:
07/31/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CRUZ
Authorized Official First Name:
REGINO
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
787-614-3006

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  9855 , 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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