Provider Demographics
NPI:1417255290
Name:VALIENTE, JORGE LUIS (LMT)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LUIS
Last Name:VALIENTE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 NW 78TH AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33126-1890
Mailing Address - Country:US
Mailing Address - Phone:305-597-3909
Mailing Address - Fax:305-597-3903
Practice Address - Street 1:1200 NW 78TH AVE STE 212
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1890
Practice Address - Country:US
Practice Address - Phone:305-597-3909
Practice Address - Fax:305-597-3903
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA58987247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other