Provider Demographics
NPI:1407830946
Name:PUERTO RICAN ORGANIZATION TO MOTIVATE ENLIGHTEN AND SERVE ADDICTS INC
Entity Type:Organization
Organization Name:PUERTO RICAN ORGANIZATION TO MOTIVATE ENLIGHTEN AND SERVE ADDICTS INC
Other - Org Name:PROMESA INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:GATELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-960-7568
Mailing Address - Street 1:311 E 175TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-5859
Mailing Address - Country:US
Mailing Address - Phone:718-960-7568
Mailing Address - Fax:718-716-7822
Practice Address - Street 1:1776 CLAY AVENUE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457
Practice Address - Country:US
Practice Address - Phone:718-299-1100
Practice Address - Fax:718-716-7822
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUERTO RICAN ORGANIZATION TO MOTIVATE ENLIGHTEN AND SERVE ADDICTS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-29
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7000226R261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00245294Medicaid
NYWX0081Medicare PIN