Provider Demographics
NPI:1780126219
Name:IBARRA MORENO, JUAN CARLOS (SA-C)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:IBARRA MORENO
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6150 DIAMOND CENTRE CT # 1300
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4367
Mailing Address - Country:US
Mailing Address - Phone:239-344-9786
Mailing Address - Fax:
Practice Address - Street 1:6150 DIAMOND CENTRE CT UNIT 1200
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-7135
Practice Address - Country:US
Practice Address - Phone:239-344-9786
Practice Address - Fax:239-344-9215
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13-514246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant