1396190369 NPI number — LUIS JIMENEZ

Table of content: LUIS JIMENEZ (NPI 1396190369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396190369 NPI number — LUIS JIMENEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JIMENEZ
Provider First Name:
LUIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396190369
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4313 AVE CONSTANCIA
Provider Second Line Business Mailing Address:
URB. ESTANCIAS DEL CARMEN
Provider Business Mailing Address City Name:
PONCE
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00716-2155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-597-7548
Provider Business Mailing Address Fax Number:
787-844-0772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4313 AVE CONSTANCIA
Provider Second Line Business Practice Location Address:
URB ESTANCIAS DEL CARMEN
Provider Business Practice Location Address City Name:
PONCE
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00716-9999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-597-7548
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  1234 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4782470 . This is a "LICENCIA DE CONDUCIR" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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