Healthcare Provider Details

I. General information

NPI: 1114129889
Provider Name (Legal Business Name): HOGAR DIVINO NINO JESUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARRETERA 854 KM 3.5
TOA BAJA PR
00951
US

IV. Provider business mailing address

P O BOX 2464
TOA BAJA PR
00951-2662
US

V. Phone/Fax

Practice location:
  • Phone: 787-794-0020
  • Fax: 787-794-3792
Mailing address:
  • Phone: 787-794-0020
  • Fax: 787-794-3792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberCDTD0174
License Number StatePR

VIII. Authorized Official

Name: MR. CARLOS J PACHECO
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 787-794-0020