=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295177269
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EUREKA MENTAL HEALTH & WELLNES CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2013
-----------------------------------------------------
Last Update Date | 07/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | PR-4494 KM 2.6 PLAZA CAMUY BUILDING
-----------------------------------------------------
City | CAMUY
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-427-4722
-----------------------------------------------------
Fax | 787-854-0650
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 30500 PMB 247
-----------------------------------------------------
City | MANATI
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-427-4722
-----------------------------------------------------
Fax | 787-854-0650
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | DR. SONIA MARIA MEDINA
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 787-427-4722
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number | 005177
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 005177
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------