1396763561 NPI number — CENTRO INTERDISCIPLINARIO DE SALUD MENTAL, C.S.P

Table of content: (NPI 1396763561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396763561 NPI number — CENTRO INTERDISCIPLINARIO DE SALUD MENTAL, C.S.P

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRO INTERDISCIPLINARIO DE SALUD MENTAL, C.S.P
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:
6
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:
1396763561
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 632
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERCEDITA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00715-0632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-453-8666
Provider Business Mailing Address Fax Number:
787-841-4170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CENTRO CARIBE BUILDING 2053
Provider Second Line Business Practice Location Address:
PONCE BY PASS SUITE 205
Provider Business Practice Location Address City Name:
PONCE
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00717-1308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-453-8666
Provider Business Practice Location Address Fax Number:
787-841-4170
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LADO-CORNEJO
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-453-8666

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  12657 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 2334 , 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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