=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154864361
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSTITUTO DE INTEGRACION Y PRESERVACION FAMILIAR PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2016
-----------------------------------------------------
Last Update Date | 11/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 AVE FD ROOSEVELT
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-690-0598
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1215 AVE FD ROOSEVELT
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-690-0598
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENTE
-----------------------------------------------------
Name | LUIS RIVERA SANTIAGO SR.
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 787-690-0598
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | 9458
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------