Provider Demographics
NPI:1093215139
Name:FENEQUE, JOSE LUIS
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:LUIS
Last Name:FENEQUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 2847
Mailing Address - Street 2:
Mailing Address - City:ANASCO
Mailing Address - State:PR
Mailing Address - Zip Code:00610-9416
Mailing Address - Country:US
Mailing Address - Phone:787-236-0264
Mailing Address - Fax:
Practice Address - Street 1:1156 CALLE 62 SE
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-2724
Practice Address - Country:US
Practice Address - Phone:787-758-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6163844390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program