Healthcare Provider Details

I. General information

NPI: 1952091704
Provider Name (Legal Business Name): RALDIC JIMENEZ LLUBERES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 09/22/2024
Certification Date: 09/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21298 OLEAN BLVD
PORT CHARLOTTE FL
33952-6705
US

IV. Provider business mailing address

24019 MADACA LN UNIT 107
PORT CHARLOTTE FL
33954-2810
US

V. Phone/Fax

Practice location:
  • Phone: 941-629-1181
  • Fax:
Mailing address:
  • Phone: 939-287-8845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3868
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11012731
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: