Provider Demographics
NPI:1780474247
Name:JIMENEZ, SELIA RENE (LMT)
Entity type:Individual
Prefix:
First Name:SELIA
Middle Name:RENE
Last Name:JIMENEZ
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5175
Mailing Address - Street 2:
Mailing Address - City:SUGARLOAF
Mailing Address - State:CA
Mailing Address - Zip Code:92386-0875
Mailing Address - Country:US
Mailing Address - Phone:909-863-3020
Mailing Address - Fax:
Practice Address - Street 1:40585 BIG BEAR BLVD STE 4
Practice Address - Street 2:
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315-2171
Practice Address - Country:US
Practice Address - Phone:909-863-3020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11572225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty