Healthcare Provider Details

I. General information

NPI: 1104803311
Provider Name (Legal Business Name): JIMENEZ DE PENA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8360 SW 8TH ST
MIAMI FL
33144-4180
US

IV. Provider business mailing address

8360 SW 8TH ST
MIAMI FL
33144-4180
US

V. Phone/Fax

Practice location:
  • Phone: 305-267-6165
  • Fax: 305-267-6156
Mailing address:
  • Phone: 305-267-6165
  • Fax: 305-267-6156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberHCC4399
License Number StateFL

VIII. Authorized Official

Name: RAUL BOZA
Title or Position: PRESIDENT
Credential:
Phone: 305-281-6066