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General NPI Number Information
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NPI Number | 1346502630
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Entity Type | Organization
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Legal Business Name | MDM GROUP
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Dates
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Enumeration Date | 06/12/2012
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Last Update Date | 06/12/2012
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Provider Practice Location Address
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Address Line | 1225 AVE PONCE DE LEON VIG TOWER SUITE 801
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City | SANTURCE
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State | PR
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Zip | 00907-3907
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Country | US
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Telephone | 787-721-0274
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Fax | 787-757-8969
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Provider Business Mailing Address
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Address Line | PO BOX 19718
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City | SAN JUAN
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State | PR
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Zip | 00910-1718
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Country | US
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Telephone | 787-721-0274
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Fax | 787-757-8969
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JUAN NIEVES
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Credential |
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Telephone | 787-721-0274
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number | 1386714251
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License Number State | PR
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