Provider Demographics
NPI:1225503568
Name:IDENTITY HEALTH GROUP INC
Entity Type:Organization
Organization Name:IDENTITY HEALTH GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:PRATS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:939-699-6013
Mailing Address - Street 1:PO BOX 1092
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:PR
Mailing Address - Zip Code:00677-1092
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47 CALLE MUNOZ RIVERA W
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:PR
Practice Address - Zip Code:00677-2125
Practice Address - Country:US
Practice Address - Phone:939-699-6013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty