Healthcare Provider Details

I. General information

NPI: 1306424270
Provider Name (Legal Business Name): CARLOS ENRIQUE ESCALONA JIMENEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6829 SW 21ST ST
MIAMI FL
33155-1735
US

IV. Provider business mailing address

6829 SW 21ST ST
MIAMI FL
33155-1735
US

V. Phone/Fax

Practice location:
  • Phone: 786-671-9976
  • Fax:
Mailing address:
  • Phone: 786-671-9976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number21-157669
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: