Provider Demographics
NPI:1790414530
Name:PSIDEP LLC
Entity Type:Organization
Organization Name:PSIDEP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ABDIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNIZ VERA
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:787-546-7508
Mailing Address - Street 1:PO BOX 1106
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-1106
Mailing Address - Country:US
Mailing Address - Phone:787-546-7508
Mailing Address - Fax:
Practice Address - Street 1:MOCA MEDICAL PLAZA #113 CARR 110 KM 12.4
Practice Address - Street 2:
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676
Practice Address - Country:US
Practice Address - Phone:787-546-7508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health