Healthcare Provider Details

I. General information

NPI: 1063686368
Provider Name (Legal Business Name): JGM PSYCHIATRY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COND MENDEZ VIGO W # 63E COND. CENTRO PLAZA OFIC. 5A
MAYAGUEZ PR
00680-2800
US

IV. Provider business mailing address

MENDEZ VIGO 63 E COND. CENTRO PLAZA OFIC. 5A
MAYAGUEZ PR
00680
US

V. Phone/Fax

Practice location:
  • Phone: 787-265-0370
  • Fax: 787-265-0370
Mailing address:
  • Phone: 787-265-0370
  • Fax: 787-265-0370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number11940
License Number StatePR

VIII. Authorized Official

Name: DR. JAPHET GAZTAMBIDE
Title or Position: PSYCHIATRY
Credential: M.D.
Phone: 787-265-0370