MEDICARE: FUNDACION MODESTO GOTAY PRO PERSONAS CON DISCAPACIDAD INTELECTUAL Y DE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	3	PR

General Provider Information

NPI Number	:	1235580143
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNDACION MODESTO GOTAY PRO PERSONAS CON DISCAPACIDAD INTELECTUAL Y DE

Provider Business Mailing Address
First Line	:	PO BOX 665
Second Line	:
City	:	TRUJILLO ALTO
State	:	PR
Zip	:	00977-0665
Country	:	US
Telephone Number	:	787-761-6244
Fax Number	:	787-200-4409

Provider Business Practice Location Address
First Line	:	CARR 876 KM 4.6
Second Line	:	BO. LAS CUEVAS
City	:	TRUJILLO ALTO
State	:	PR
Zip	:	00976-0000
Country	:	US
Telephone Number	:	787-761-6244
Fax Number	:	787-200-4409

Authorized Official
Title or Position	:	ADMINISTRATIVE ASSISTANT
Name	:	MS. NILKA R. ENCARNACION
Credential	:
Telephone Number	:	787-761-6244

Provider Enumeration Date	:	06/22/2016
Last Update Date	:	06/22/2016

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