Healthcare Provider Details

I. General information

NPI: 1295373348
Provider Name (Legal Business Name): JOSE LUIS FANJUL RIVERO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 04/05/2026
Certification Date: 04/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 W 10TH AVE
HIALEAH FL
33010-1907
US

IV. Provider business mailing address

200 KNUTH RD STE 202
BOYNTON BEACH FL
33436-4629
US

V. Phone/Fax

Practice location:
  • Phone: 305-888-7059
  • Fax:
Mailing address:
  • Phone: 786-307-3571
  • Fax: 305-999-1682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-47515
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: