Healthcare Provider Details

I. General information

NPI: 1164630109
Provider Name (Legal Business Name): ASSMCA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 AVE HOSTOS STE 7 ASSMCA, MEDIACL CENTER
MAYAGUEZ PR
00682-1500
US

IV. Provider business mailing address

424 CUMBRES DE MIRADERO
MAYAGUEZ PR
00682-7518
US

V. Phone/Fax

Practice location:
  • Phone: 787-832-6771
  • Fax: 787-832-6771
Mailing address:
  • Phone: 787-834-0598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number4396
License Number StatePR

VIII. Authorized Official

Name: MR. WILSON IVAN GONZALEZ
Title or Position: SOCIAL WORKER
Credential: SW
Phone: 787-832-6771