Basic Information
Provider Information
NPI: 1821523432
EntityType: 2
ReplacementNPI:  
OrganizationName: SAN JORGE PEDIATRIC MENTAL HEALTH UNIT
LastName:  
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Credential:  
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Mailing Information
Address1: 253 CALLE SAN JORGE
Address2: SAN JORGE CORPORATE BUILDING 2B
City: SAN JUAN
State: PR
PostalCode: 00912
CountryCode: US
TelephoneNumber: 7877271000
FaxNumber: 7872688702
Practice Location
Address1: 253 CALLE SAN JORGE
Address2: SAN JORGE CORPORATE BUILDING 2B
City: SAN JUAN
State: PR
PostalCode: 00912
CountryCode: US
TelephoneNumber: 7877271000
FaxNumber: 7872688702
Other Information
ProviderEnumerationDate: 04/21/2017
LastUpdateDate: 06/09/2020
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: RODRIGUEZ
AuthorizedOfficialFirstName: JOSE
AuthorizedOfficialMiddleName: L
AuthorizedOfficialTitleorPosition: VP & EXECUTIVE DIRECTOR
AuthorizedOfficialTelephone: 7877271000
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: SAN JORGE CHILDREN'S HOSPITAL, INC
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MHSA
NPICertificationDate: 06/09/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QM0855X  Y Ambulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health

No ID Information.


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