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General NPI Number Information
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NPI Number | 1790087609
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Entity Type | Organization
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Legal Business Name | CENTRO AMBULATORIO DE DESINTOXICACION Y ENLACE DE PR, INC.
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Dates
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Enumeration Date | 11/29/2010
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Last Update Date | 11/29/2010
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Provider Practice Location Address
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Address Line | ATOCHA 120
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City | PONCE
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State | PR
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Zip | 00731
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Country | US
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Telephone | 787-409-7030
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2000 PMB 10
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City | MERCEDITA
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State | PR
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Zip | 00717
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Country | US
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Telephone | 787-409-7030
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. MARTIN SCAMARONI
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Credential | M.D.
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Telephone | 787-407-8944
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | LOC-15-62-0004
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License Number State | PR
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | AC-15-62-0034
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License Number State | PR
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