=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780227504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRAVAN WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2019
-----------------------------------------------------
Last Update Date | 10/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1511 AVE PONCE DE LEON STE 3
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00909-5001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-310-7900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1511 AVE PONCE DE LEON STE 3
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00909-5001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-339-2639
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT OF OPERATIONS
-----------------------------------------------------
Name | DR. RUTH L GONZALEZ
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 787-310-7900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------