Provider Demographics
NPI:1356080923
Name:CARVAJALES DIEGUEZ, LESTER OMAR
Entity Type:Individual
Prefix:
First Name:LESTER
Middle Name:OMAR
Last Name:CARVAJALES DIEGUEZ
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 1:6420 SW 139TH AVENUE RD APT 302
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-2520
Mailing Address - Country:US
Mailing Address - Phone:786-970-9301
Mailing Address - Fax:
Practice Address - Street 1:1893 NE MIAMI GARDENS DR
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179-5035
Practice Address - Country:US
Practice Address - Phone:305-682-0080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31913225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty