Provider Demographics
NPI:1982031480
Name:MENJIVAR, LUIS EMILIO (LPN)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:EMILIO
Last Name:MENJIVAR
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 CRYSTAL DR
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11937-2031
Mailing Address - Country:US
Mailing Address - Phone:631-721-6550
Mailing Address - Fax:
Practice Address - Street 1:76 CRYSTAL DR
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937-2031
Practice Address - Country:US
Practice Address - Phone:631-721-6550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315921-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse