Provider Demographics
NPI:1396763561
Name:CENTRO INTERDISCIPLINARIO DE SALUD MENTAL, C.S.P
Entity type:Organization
Organization Name:CENTRO INTERDISCIPLINARIO DE SALUD MENTAL, C.S.P
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:A
Authorized Official - Last Name:LADO-CORNEJO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-453-8666
Mailing Address - Street 1:PO BOX 632
Mailing Address - Street 2:
Mailing Address - City:MERCEDITA
Mailing Address - State:PR
Mailing Address - Zip Code:00715-0632
Mailing Address - Country:US
Mailing Address - Phone:787-453-8666
Mailing Address - Fax:787-841-4170
Practice Address - Street 1:CENTRO CARIBE BUILDING 2053
Practice Address - Street 2:PONCE BY PASS SUITE 205
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1308
Practice Address - Country:US
Practice Address - Phone:787-453-8666
Practice Address - Fax:787-841-4170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR126572084P0800X
PR2334103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRQ-18576Medicare UPIN
PR0056737Medicare ID - Type Unspecified