Healthcare Provider Details

I. General information

NPI: 1730539644
Provider Name (Legal Business Name): THE BEHAVIORAL GROUP, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COND MAGA BO MONACILLOS CENTRO MEDICO
SAN JUAN PR
00907-1966
US

IV. Provider business mailing address

130 AVE WINSTON CHURCHILL PMB 359 SUITE 1
SAN JUAN PR
00926-6065
US

V. Phone/Fax

Practice location:
  • Phone: 787-545-2718
  • Fax: 787-545-2794
Mailing address:
  • Phone: 787-545-2718
  • Fax: 787-545-2794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number13958
License Number StatePR

VIII. Authorized Official

Name: DR. JORGE MEJIA VALLE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-545-2718