Provider Demographics
NPI:1205175098
Name:HENRIQUEZ, EMMANUEL ALEJANDRO
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:ALEJANDRO
Last Name:HENRIQUEZ
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 1:6071 71ST AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-5157
Mailing Address - Country:US
Mailing Address - Phone:917-375-8238
Mailing Address - Fax:
Practice Address - Street 1:6071 71ST AVE FL 2
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-5157
Practice Address - Country:US
Practice Address - Phone:917-375-8238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY555171111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist