Provider Demographics
NPI:1639582844
Name:MUNICIPALITY OF SAN JUAN
Entity Type:Organization
Organization Name:MUNICIPALITY OF SAN JUAN
Other - Org Name:GRUPO CLINICO SALUD MENTAL CDT DR. GUALBERTO RABELL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSOCOLOGICAL SERVICE SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:SANTIAGO
Authorized Official - Last Name:CONCEPCION
Authorized Official - Suffix:
Authorized Official - Credentials:PHD MBA
Authorized Official - Phone:787-480-3828
Mailing Address - Street 1:PO BOX 21405
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00928-1405
Mailing Address - Country:US
Mailing Address - Phone:787-480-3828
Mailing Address - Fax:787-977-8401
Practice Address - Street 1:CALLE CERRA FINAL ESQ CALLE HOARE #900
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00928-1405
Practice Address - Country:US
Practice Address - Phone:787-480-3828
Practice Address - Fax:787-977-8401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR101 CNC NUM 78-262261QM0850X
PR101 CNC 78-262261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR400015Medicare PIN