Healthcare Provider Details

I. General information

NPI: 1639907124
Provider Name (Legal Business Name): IVAN CUEVAS INCLAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3029 CLYDE RD
WEST PALM BEACH FL
33405-1309
US

IV. Provider business mailing address

3029 CLYDE RD
WEST PALM BEACH FL
33405-1309
US

V. Phone/Fax

Practice location:
  • Phone: 561-247-5318
  • Fax:
Mailing address:
  • Phone: 561-247-5318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-355639
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: