Healthcare Provider Details

I. General information

NPI: 1790087609
Provider Name (Legal Business Name): CENTRO AMBULATORIO DE DESINTOXICACION Y ENLACE DE PR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ATOCHA 120
PONCE PR
00731
US

IV. Provider business mailing address

PO BOX 2000 PMB 10
MERCEDITA PR
00717
US

V. Phone/Fax

Practice location:
  • Phone: 787-409-7030
  • Fax:
Mailing address:
  • Phone: 787-409-7030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLOC-15-62-0004
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAC-15-62-0034
License Number StatePR

VIII. Authorized Official

Name: DR. MARTIN SCAMARONI
Title or Position: CEO
Credential: M.D.
Phone: 787-407-8944