Provider Demographics
NPI:1992103014
Name:CERVANTES, JOSE LUIS (LMP)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:LUIS
Last Name:CERVANTES
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13904 100TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-5231
Mailing Address - Country:US
Mailing Address - Phone:425-820-5888
Mailing Address - Fax:425-820-5022
Practice Address - Street 1:13904 100TH AVE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-5231
Practice Address - Country:US
Practice Address - Phone:425-820-5888
Practice Address - Fax:425-820-5022
Is Sole Proprietor?:No
Enumeration Date:2014-12-06
Last Update Date:2014-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60288727225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist