Healthcare Provider Details

I. General information

NPI: 1194737189
Provider Name (Legal Business Name): CLINICA INTERDISCIPLINARIA DE PSIQUIATRIA AVANZADA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 CALLE LLOVERAS EDIF CENTRO PLAZA SUITE 101
SAN JUAN PR
00909-2110
US

IV. Provider business mailing address

650 CALLE LLOVERAS EDIF CENTRO PLAZA SUITE 101
SAN JUAN PR
00909-2110
US

V. Phone/Fax

Practice location:
  • Phone: 787-721-4020
  • Fax: 787-721-4555
Mailing address:
  • Phone: 787-721-4020
  • Fax: 787-721-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number7800
License Number StatePR

VIII. Authorized Official

Name: DR. CARLOS AUGUSTO CABAN
Title or Position: PRESIDENT
Credential: MD
Phone: 787-721-4020