Healthcare Provider Details

I. General information

NPI: 1386987212
Provider Name (Legal Business Name): PUERTO RICAN ORGANIZATION TO MOTIVATE ENLIGHTEN AND SERVE ADDICTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1776 CLAY AVE
BRONX NY
10457
US

IV. Provider business mailing address

1776 CLAY AVE
BRONX NY
10457-7239
US

V. Phone/Fax

Practice location:
  • Phone: 718-299-1100
  • Fax: 718-716-7822
Mailing address:
  • Phone: 718-299-1100
  • Fax: 718-716-7822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MILTON DERIENZO
Title or Position: CFO
Credential:
Phone: 347-649-3083