Provider Demographics
NPI:1629966007
Name:CENTRO INDIVIDUAL DE MEDICINA ESPECIALIZADA LLC
Entity type:Organization
Organization Name:CENTRO INDIVIDUAL DE MEDICINA ESPECIALIZADA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AILED
Authorized Official - Middle Name:RIVERA
Authorized Official - Last Name:SOTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-354-2514
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00984-1475
Mailing Address - Country:US
Mailing Address - Phone:787-354-2514
Mailing Address - Fax:
Practice Address - Street 1:140 AVE LAS CUMBRES
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969-5523
Practice Address - Country:US
Practice Address - Phone:787-731-5785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-25
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR10166Medicaid