Provider Demographics
NPI:1952718264
Name:OPTIMIND MANAGED BEHAVIORAL HEALTHCARE ORGANIZATION CORPORATION
Entity Type:Organization
Organization Name:OPTIMIND MANAGED BEHAVIORAL HEALTHCARE ORGANIZATION CORPORATION
Other - Org Name:OPTIMIND CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PESQUERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-522-4618
Mailing Address - Street 1:PO BOX 20000
Mailing Address - Street 2:
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729-0042
Mailing Address - Country:US
Mailing Address - Phone:787-522-4618
Mailing Address - Fax:787-522-4619
Practice Address - Street 1:CARR. #3 KM. 13.4
Practice Address - Street 2:BO. CANOVANILLAS
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00984-0042
Practice Address - Country:US
Practice Address - Phone:787-522-4618
Practice Address - Fax:787-522-4619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRPAE013302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization