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General NPI Number Information
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NPI Number | 1952718264
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Entity Type | Organization
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Legal Business Name | OPTIMIND MANAGED BEHAVIORAL HEALTHCARE ORGANIZATION CORPORATION
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Dates
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Enumeration Date | 07/18/2014
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Last Update Date | 07/18/2014
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Provider Practice Location Address
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Address Line | CARR. #3 KM. 13.4 BO. CANOVANILLAS
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City | CAROLINA
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State | PR
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Zip | 00984-0042
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Country | US
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Telephone | 787-522-4618
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Fax | 787-522-4619
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Provider Business Mailing Address
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Address Line | PO BOX 20000
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City | CANOVANAS
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State | PR
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Zip | 00729-0042
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Country | US
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Telephone | 787-522-4618
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Fax | 787-522-4619
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. JORGE L PESQUERA
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Credential |
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Telephone | 787-522-4618
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | PAE013
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License Number State | PR
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