Provider Demographics
NPI:1609280072
Name:CDT ASOCIACION DE MAESTROS MAYAGUEZ
Entity Type:Organization
Organization Name:CDT ASOCIACION DE MAESTROS MAYAGUEZ
Other - Org Name:CDTMAYAGUEZ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CDT ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANTONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDINO RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MHSA
Authorized Official - Phone:787-763-5560
Mailing Address - Street 1:452 AVE PONCE DE LEON
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-3490
Mailing Address - Country:US
Mailing Address - Phone:787-763-5560
Mailing Address - Fax:787-767-6600
Practice Address - Street 1:452 AVE PONCE DE LEON
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3490
Practice Address - Country:US
Practice Address - Phone:787-763-5560
Practice Address - Fax:787-767-6600
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASOCIACION DE MAESTROS DE PUERTO RICO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR134261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
0010098Medicare PIN