Healthcare Provider Details

I. General information

NPI: 1326686742
Provider Name (Legal Business Name): EMBAJADORA BY INNOVATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192-14 CALLE 435
CAROLINA PR
00985-3013
US

IV. Provider business mailing address

PO BOX 5127
CAROLINA PR
00984-5127
US

V. Phone/Fax

Practice location:
  • Phone: 787-518-5720
  • Fax:
Mailing address:
  • Phone: 787-518-5720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number StateNULL

VIII. Authorized Official

Name: INGRIS MALDONADO
Title or Position: PRESIDENTA
Credential: PHD
Phone: 939-655-7983