Provider Demographics
NPI:1386046837
Name:CHAMPI MEDICAL AND WELLNESS GROUP CORP
Entity type:Organization
Organization Name:CHAMPI MEDICAL AND WELLNESS GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:COSMARIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:CORTES-RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-229-1223
Mailing Address - Street 1:PO BOX 619
Mailing Address - Street 2:
Mailing Address - City:ANASCO
Mailing Address - State:PR
Mailing Address - Zip Code:00610-0619
Mailing Address - Country:US
Mailing Address - Phone:787-229-1223
Mailing Address - Fax:787-229-1332
Practice Address - Street 1:107 CALLE MARIA MONAGAS LOCAL #1
Practice Address - Street 2:ESQ 65 INFANTERIA MENTAL HEALTH DIVISION
Practice Address - City:ANASCO
Practice Address - State:PR
Practice Address - Zip Code:00610
Practice Address - Country:US
Practice Address - Phone:787-229-1223
Practice Address - Fax:787-229-1332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR103G00000X, 103TC0700X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty