Provider Demographics
NPI:1821290917
Name:ALFONSO F JIMENEZ
Entity Type:Organization
Organization Name:ALFONSO F JIMENEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:F
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:808-689-4414
Mailing Address - Street 1:91-896 MAKULE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-2543
Mailing Address - Country:US
Mailing Address - Phone:808-689-4414
Mailing Address - Fax:808-689-7115
Practice Address - Street 1:91-896 MAKULE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-2543
Practice Address - Country:US
Practice Address - Phone:808-689-4414
Practice Address - Fax:808-689-7115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH54602OtherMEDICARE PROVIDER NUMBER
HIH54603OtherMEDICARE PROVIDER NUMBER
HIH54601OtherMEDICARE PROVIDER NUMBER
HIH54601OtherMEDICARE PROVIDER NUMBER