Healthcare Provider Details

I. General information

NPI: 1528475035
Provider Name (Legal Business Name): NEURO GI WELLNESS CENTRE, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 AVE WINSTON CHURCHILL STE 201
SAN JUAN PR
00926-6655
US

IV. Provider business mailing address

PO BOX 1132
TRUJILLO ALTO PR
00977-1132
US

V. Phone/Fax

Practice location:
  • Phone: 787-283-0804
  • Fax: 787-761-5764
Mailing address:
  • Phone: 787-283-0804
  • Fax: 787-761-5764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number12865
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number12865
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number12278
License Number StatePR

VIII. Authorized Official

Name: HENRY GONZALEZ-RIVERA
Title or Position: PRESIDENT
Credential: M.D
Phone: 787-283-0408