Provider Demographics
NPI:1790087609
Name:CENTRO AMBULATORIO DE DESINTOXICACION Y ENLACE DE PR, INC.
Entity Type:Organization
Organization Name:CENTRO AMBULATORIO DE DESINTOXICACION Y ENLACE DE PR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCAMARONI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-407-8944
Mailing Address - Street 1:PO BOX 2000 PMB 10
Mailing Address - Street 2:
Mailing Address - City:MERCEDITA
Mailing Address - State:PR
Mailing Address - Zip Code:00717
Mailing Address - Country:US
Mailing Address - Phone:787-409-7030
Mailing Address - Fax:
Practice Address - Street 1:ATOCHA 120
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00731
Practice Address - Country:US
Practice Address - Phone:787-409-7030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRLOC-15-62-0004101Y00000X
PRAC-15-62-0034101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty