Healthcare Provider Details

I. General information

NPI: 1568207314
Provider Name (Legal Business Name): LEONEL JIMENEZ EGOZCUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8180 NW 36TH ST STE 317
DORAL FL
33166-6674
US

IV. Provider business mailing address

8180 NW 36TH ST STE 317
DORAL FL
33166-6674
US

V. Phone/Fax

Practice location:
  • Phone: 786-652-1513
  • Fax:
Mailing address:
  • Phone: 786-652-1513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-354669
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: