Healthcare Provider Details

I. General information

NPI: 1629966007
Provider Name (Legal Business Name): CENTRO INDIVIDUAL DE MEDICINA ESPECIALIZADA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 AVE LAS CUMBRES
GUAYNABO PR
00969-5523
US

IV. Provider business mailing address

PO BOX 1475
CAROLINA PR
00984-1475
US

V. Phone/Fax

Practice location:
  • Phone: 787-731-5785
  • Fax:
Mailing address:
  • Phone: 787-354-2514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. AILED RIVERA SOTO
Title or Position: ADMINISTRATOR
Credential:
Phone: 787-354-2514