=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326478371
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERVICIOS INTEGRADOS DE SALUD MENTAL S.E.P.I.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2013
-----------------------------------------------------
Last Update Date | 11/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | EDIFICIO CARIBBEAN OFFICE PARK CARR 417 BO MALPASO
-----------------------------------------------------
City | AGUADA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-868-1828
-----------------------------------------------------
Fax | 787-868-1828
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 CALLE COLON
-----------------------------------------------------
City | AGUADA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-868-1828
-----------------------------------------------------
Fax | 787-868-1828
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ILIANETTE RUIZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 787-868-1828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 20389
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number | 20389
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------