Provider Demographics
NPI:1720379704
Name:CORDA OF PR INC
Entity Type:Organization
Organization Name:CORDA OF PR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LHD, DD, TAC III
Authorized Official - Phone:787-636-5443
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00792-0220
Mailing Address - Country:US
Mailing Address - Phone:787-636-4741
Mailing Address - Fax:787-285-1890
Practice Address - Street 1:CARR 910 INT KM 4.3 BO CATANO
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00792
Practice Address - Country:US
Practice Address - Phone:787-636-4741
Practice Address - Fax:787-285-1890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRCTRSA-0243324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility