Healthcare Provider Details

I. General information

NPI: 1639455611
Provider Name (Legal Business Name): INSTITUTO MULTIDISCIPLINARIO Y EDUCATIVO DEL CENTRO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2011
Last Update Date: 10/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE ANTONIO R BARCELO KM 73.6
CAYEY PR
00736-3717
US

IV. Provider business mailing address

PO BOX 6400 SUITE 118
CAYEY PR
00737-6400
US

V. Phone/Fax

Practice location:
  • Phone: 787-263-8108
  • Fax: 787-263-8108
Mailing address:
  • Phone: 787-263-8108
  • Fax: 787-263-8108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number898
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number898
License Number StatePR

VIII. Authorized Official

Name: MRS. ALBA IRIS CASTILLO
Title or Position: DIRECTOR
Credential:
Phone: 787-263-8108