Healthcare Provider Details

I. General information

NPI: 1508391806
Provider Name (Legal Business Name): JORGE IRULEGUI ALVAREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8840 FONTAINEBLEAU BLVD
MIAMI FL
33172-4463
US

IV. Provider business mailing address

2500 NW 79TH AVE STE 116
DORAL FL
33122-1075
US

V. Phone/Fax

Practice location:
  • Phone: 786-263-3763
  • Fax:
Mailing address:
  • Phone: 305-591-7898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-57274
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: