Provider Demographics
NPI:1598161077
Name:ALICEA, LUIS III (ATC)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:ALICEA
Suffix:III
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2869 BAINBRIDGE AVE APT 2C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-2830
Mailing Address - Country:US
Mailing Address - Phone:718-584-8633
Mailing Address - Fax:
Practice Address - Street 1:2869 BAINBRIDGE AVE APT 2C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-2830
Practice Address - Country:US
Practice Address - Phone:718-584-8633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20000189952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer