Provider Demographics
NPI:1508391806
Name:IRULEGUI ALVAREZ, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:IRULEGUI ALVAREZ
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 1:2500 NW 79TH AVE STE 116
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33122-1075
Mailing Address - Country:US
Mailing Address - Phone:305-591-7898
Mailing Address - Fax:
Practice Address - Street 1:8840 FONTAINEBLEAU BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-4463
Practice Address - Country:US
Practice Address - Phone:786-263-3763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-57274106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician