Provider Demographics
NPI:1760817977
Name:JIMENEZ RINCON, LUIS ALFONSE
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ALFONSE
Last Name:JIMENEZ RINCON
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 1:3501 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7916
Mailing Address - Country:US
Mailing Address - Phone:918-813-3826
Mailing Address - Fax:
Practice Address - Street 1:3501 S 1ST ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7916
Practice Address - Country:US
Practice Address - Phone:918-813-3826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health