Provider Demographics
NPI:1336768852
Name:ACABA-BERROCAL, LUIS ALEJANDRO
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ALEJANDRO
Last Name:ACABA-BERROCAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LUIS
Other - Middle Name:
Other - Last Name:ACABA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:840 S WOOD ST RM 427
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1855 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7242
Practice Address - Country:US
Practice Address - Phone:312-996-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program