Provider Demographics
NPI:1487856902
Name:PROGRAMA DE SERVICIO RESIDENCIAL PARA NINOS Y ADOLESCENTES
Entity Type:Organization
Organization Name:PROGRAMA DE SERVICIO RESIDENCIAL PARA NINOS Y ADOLESCENTES
Other - Org Name:ASSMCA
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR DE FACTURACION
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:B'AEZ SALGADO
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:787-763-7575
Mailing Address - Street 1:PO BOX 607087
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00960-7087
Mailing Address - Country:US
Mailing Address - Phone:787-763-7575
Mailing Address - Fax:
Practice Address - Street 1:CARR #2 KM 8.2
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-783-0750
Practice Address - Fax:787-781-8129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10835163W00000X
163W00000X, 261QM0855X, 323P00000X, 364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment FacilityGroup - Multi-Specialty
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR038813200Medicaid