Provider Demographics
NPI:1497344030
Name:HERNANDEZ, MARK LUIS LIM
Entity Type:Individual
Prefix:
First Name:MARK LUIS
Middle Name:LIM
Last Name:HERNANDEZ
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 1:414 HACKENSACK AVE APT 2418
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-6339
Mailing Address - Country:US
Mailing Address - Phone:641-525-0706
Mailing Address - Fax:
Practice Address - Street 1:414 HACKENSACK AVE APT 2418
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-6339
Practice Address - Country:US
Practice Address - Phone:641-525-0706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-17
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer