Provider Demographics
NPI:1164976445
Name:IBARRA, ALEX FABIAN
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:FABIAN
Last Name:IBARRA
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 1:1180 E HALLANDALE BEACH BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4436
Mailing Address - Country:US
Mailing Address - Phone:954-454-5559
Mailing Address - Fax:844-245-1408
Practice Address - Street 1:1180 E HALLANDALE BEACH BLVD
Practice Address - Street 2:STE B
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4436
Practice Address - Country:US
Practice Address - Phone:954-454-5559
Practice Address - Fax:844-245-1408
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA73637225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist