Provider Demographics
NPI:1972189298
Name:MANTIS WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:MANTIS WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRADOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ NIEVES
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:787-360-9657
Mailing Address - Street 1:URB FLAMINGO TERRACE A7 MARG 167
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00957
Mailing Address - Country:US
Mailing Address - Phone:787-981-3037
Mailing Address - Fax:
Practice Address - Street 1:URB FLAMINGO TERRACE A7 MARG 167
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00957
Practice Address - Country:US
Practice Address - Phone:787-981-3037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty