Healthcare Provider Details

I. General information

NPI: 1124507520
Provider Name (Legal Business Name): JOSE ENRIQUE COSME GRULLON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 BUDINGER AVE
SAINT CLOUD FL
34769-7203
US

IV. Provider business mailing address

12124 CALABOOSE CT
ORLANDO FL
32828-8977
US

V. Phone/Fax

Practice location:
  • Phone: 407-891-3054
  • Fax: 888-477-7678
Mailing address:
  • Phone: 939-358-7056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number11418
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: