Provider Demographics
NPI:1902202377
Name:GERENA, JOSE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:GERENA
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 1:3680 LAKE CENTER DR 1104
Mailing Address - Street 2:
Mailing Address - City:MT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757
Mailing Address - Country:US
Mailing Address - Phone:888-501-2586
Mailing Address - Fax:
Practice Address - Street 1:11325 VILLAGE BROOK DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579
Practice Address - Country:US
Practice Address - Phone:888-501-2586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL233767372600000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL233767Medicaid