Healthcare Provider Details

I. General information

NPI: 1396581617
Provider Name (Legal Business Name): MR. LENNYS LUQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2024
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 W MOUNTAIN ST
PASADENA CA
91103-2967
US

IV. Provider business mailing address

2222 HUNTINGTON DR APT 27
DUARTE CA
91010-4300
US

V. Phone/Fax

Practice location:
  • Phone: 323-924-9084
  • Fax: 213-723-2087
Mailing address:
  • Phone: 404-748-5508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: