Provider Demographics
NPI:1396190369
Name:JIMENEZ, LUIS
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:JIMENEZ
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 1:4313 AVE CONSTANCIA
Mailing Address - Street 2:URB. ESTANCIAS DEL CARMEN
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716-2155
Mailing Address - Country:US
Mailing Address - Phone:787-597-7548
Mailing Address - Fax:787-844-0772
Practice Address - Street 1:4313 AVE CONSTANCIA
Practice Address - Street 2:URB ESTANCIAS DEL CARMEN
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-9999
Practice Address - Country:US
Practice Address - Phone:787-597-7548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1234225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4782470OtherLICENCIA DE CONDUCIR