Provider Demographics
NPI:1235580143
Name:FUNDACION MODESTO GOTAY PRO PERSONAS CON DISCAPACIDAD INTELECTUAL Y DE
Entity Type:Organization
Organization Name:FUNDACION MODESTO GOTAY PRO PERSONAS CON DISCAPACIDAD INTELECTUAL Y DE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:NILKA
Authorized Official - Middle Name:R
Authorized Official - Last Name:ENCARNACION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-761-6244
Mailing Address - Street 1:PO BOX 665
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00977-0665
Mailing Address - Country:US
Mailing Address - Phone:787-761-6244
Mailing Address - Fax:787-200-4409
Practice Address - Street 1:CARR 876 KM 4.6
Practice Address - Street 2:BO. LAS CUEVAS
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976-0000
Practice Address - Country:US
Practice Address - Phone:787-761-6244
Practice Address - Fax:787-200-4409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities