Provider Demographics
NPI:1417371188
Name:ASSMCA MAYAGUEZ
Entity Type:Organization
Organization Name:ASSMCA MAYAGUEZ
Other - Org Name:ASSMCA MAYAGUEZ
Other - Org Type:Other Name
Authorized Official - Title/Position:ENFERMERO PRACTICO
Authorized Official - Prefix:MR
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:787-833-0663
Mailing Address - Street 1:410 AVE HOSTOS SUITE 7
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00682-1522
Mailing Address - Country:US
Mailing Address - Phone:787-833-0663
Mailing Address - Fax:
Practice Address - Street 1:410 AVE HOSTOS STE 7
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00682-1500
Practice Address - Country:US
Practice Address - Phone:787-833-0663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16820261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)