Provider Demographics
NPI:1851601751
Name:CARLOS, JOSE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:CARLOS
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 1:2612 W LELAND AVE
Mailing Address - Street 2:APT # 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2986
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2612 W LELAND AVE
Practice Address - Street 2:APT # 2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2986
Practice Address - Country:US
Practice Address - Phone:312-339-0653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.002854224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant