Provider Demographics
NPI:1598937641
Name:PERRENOUD, JOSE LUIS AVELLANA
Entity Type:Individual
Prefix:
First Name:JOSE LUIS
Middle Name:AVELLANA
Last Name:PERRENOUD
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 1:5489 RUTLAND CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-8918
Mailing Address - Country:US
Mailing Address - Phone:909-563-8993
Mailing Address - Fax:909-899-0725
Practice Address - Street 1:5489 RUTLAND CT
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-8918
Practice Address - Country:US
Practice Address - Phone:909-563-8993
Practice Address - Fax:909-899-0725
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 14544225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist