Provider Demographics
NPI:1972287027
Name:JIMENEZ REHABILITATION LLC
Entity Type:Organization
Organization Name:JIMENEZ REHABILITATION LLC
Other - Org Name:FOUNTAIN OF YOUTH THERAPIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED MEDICAL MASSAGE THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA 93477
Authorized Official - Phone:407-508-0768
Mailing Address - Street 1:1603 S HIAWASSEE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-6437
Mailing Address - Country:US
Mailing Address - Phone:407-508-0768
Mailing Address - Fax:
Practice Address - Street 1:1603 S HIAWASSEE RD STE 105
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6437
Practice Address - Country:US
Practice Address - Phone:407-508-0768
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-09
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation