Healthcare Provider Details

I. General information

NPI: 1386046837
Provider Name (Legal Business Name): CHAMPI MEDICAL AND WELLNESS GROUP CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 CALLE MARIA MONAGAS LOCAL #1 ESQ 65 INFANTERIA MENTAL HEALTH DIVISION
ANASCO PR
00610
US

IV. Provider business mailing address

PO BOX 619
ANASCO PR
00610-0619
US

V. Phone/Fax

Practice location:
  • Phone: 787-229-1223
  • Fax: 787-229-1332
Mailing address:
  • Phone: 787-229-1223
  • Fax: 787-229-1332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StatePR

VIII. Authorized Official

Name: DR. COSMARIE M CORTES-RIVERA
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 787-229-1223