Provider Demographics
NPI:1053455014
Name:NEURO GI WELLNESS CENTRE PSC
Entity Type:Organization
Organization Name:NEURO GI WELLNESS CENTRE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ-RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-283-0804
Mailing Address - Street 1:PO BOX 1132
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00977-1132
Mailing Address - Country:US
Mailing Address - Phone:787-283-0804
Mailing Address - Fax:787-761-5764
Practice Address - Street 1:200 AVE WINSTON CHURCHILL STE 201
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-6655
Practice Address - Country:US
Practice Address - Phone:787-283-0804
Practice Address - Fax:787-761-5764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12865207RG0100X
PR12,8652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR90340Medicare PIN
PRH90400Medicare UPIN
PR0090340Medicare PIN