Provider Demographics
NPI:1932514163
Name:JEANTILUS, LEONEL
Entity Type:Individual
Prefix:
First Name:LEONEL
Middle Name:
Last Name:JEANTILUS
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 1:4500 NW 36TH ST APT 301
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-6417
Mailing Address - Country:US
Mailing Address - Phone:954-873-1469
Mailing Address - Fax:
Practice Address - Street 1:10650 W STATE ROAD 84
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324-4235
Practice Address - Country:US
Practice Address - Phone:954-634-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010384800Medicaid