Provider Demographics
NPI:1255842829
Name:FAGUNDO PEREZ, JUAN CARLOS
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:FAGUNDO PEREZ
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 1:26055 SW 144TH AVE APT 206
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5653
Mailing Address - Country:US
Mailing Address - Phone:305-303-2482
Mailing Address - Fax:
Practice Address - Street 1:26055 SW 144TH AVE APT 206
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-5653
Practice Address - Country:US
Practice Address - Phone:305-303-2482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106S00000XMedicaid