Healthcare Provider Details

I. General information

NPI: 1679917033
Provider Name (Legal Business Name): LAWRENCE CORONEL JIMENEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2013
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 EAST AVE BLDG 3911
PENSACOLA FL
32508
US

IV. Provider business mailing address

1800 BROWN RD
PENSACOLA FL
32508-7003
US

V. Phone/Fax

Practice location:
  • Phone: 850-452-8970
  • Fax: 850-452-8978
Mailing address:
  • Phone: 619-944-5641
  • Fax: 850-452-8978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: