Healthcare Provider Details

I. General information

NPI: 1902681240
Provider Name (Legal Business Name): JEDRICK LLEVARES NOVERO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2023
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

572 SANTA THERESA CT
CHULA VISTA CA
91914-4130
US

IV. Provider business mailing address

572 SANTA THERESA CT
CHULA VISTA CA
91914-4130
US

V. Phone/Fax

Practice location:
  • Phone: 619-755-8120
  • Fax:
Mailing address:
  • Phone: 619-755-8120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: