=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528486164
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRUPO SALUD MENTAL DEL SUR, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2014
-----------------------------------------------------
Last Update Date | 04/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 609 AVE TITO CASTRO SUITES 102 PMB 229
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00716-1692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-638-3090
-----------------------------------------------------
Fax | 787-259-3331
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1306 CALLE SALUD ESQ CAMPECHE
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00717-1692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-638-3090
-----------------------------------------------------
Fax | 787-259-3331
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. JOSE X. VAZQUEZ SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-638-3090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------