Provider Demographics
NPI:1487161808
Name:MENTE RENOVADA CENTRO DE INTERVENCION CLINICA SOCIAL
Entity type:Organization
Organization Name:MENTE RENOVADA CENTRO DE INTERVENCION CLINICA SOCIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRABAJADORA SOCIAL CLINICA
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DESARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:LICENCIADA
Authorized Official - Phone:787-669-5124
Mailing Address - Street 1:219 CALLE A
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-4007
Mailing Address - Country:US
Mailing Address - Phone:787-669-5124
Mailing Address - Fax:
Practice Address - Street 1:BUEN SAMARITANO MEDICAL & PROFESSIONAL PLAZA
Practice Address - Street 2:SUITE #5 PRIMER PISO AVE. SEVERIANO CUEVAS #18
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:787-422-2595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-08
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208D00000X
PR10474261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1487963484Medicaid