1306225248 NPI number — INNOVATION MENTAL HEALTH SERVICES CORP

Table of content: (NPI 1306225248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306225248 NPI number — INNOVATION MENTAL HEALTH SERVICES CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATION MENTAL HEALTH SERVICES CORP
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:
1306225248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 CALLE
Provider Second Line Business Mailing Address:
REPARTO MONTELLANO
Provider Business Mailing Address City Name:
CAYEY
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 CALLE
Provider Second Line Business Practice Location Address:
REPARTO MONTELLANO
Provider Business Practice Location Address City Name:
CAYEY
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00736-4201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-664-1101
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/26/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
787-664-1101

Provider Taxonomy Codes

  • Taxonomy code: 103TH0100X , with the licence number:  2465 , 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: 103TH0100X , issued by the state of ( PR ) . This identifiers is of the category "MEDICAID".




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