Healthcare Provider Details

I. General information

NPI: 1942771795
Provider Name (Legal Business Name): ECOSALUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 LIRIO SAN RAFAEL ESTATES II
BAYAMON PR
00959
US

IV. Provider business mailing address

274 CALLE LIRIO
BAYAMON PR
00959-4181
US

V. Phone/Fax

Practice location:
  • Phone: 787-596-0358
  • Fax:
Mailing address:
  • Phone: 787-596-0358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LESLIE E DOMINGUEZ
Title or Position: SOLE PROPIETOR
Credential: M.A
Phone: 787-596-0358