Healthcare Provider Details

I. General information

NPI: 1043581010
Provider Name (Legal Business Name): CARLOS JESUS JANZEN P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2012
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15204 W COLONIAL DR
WINTER GARDEN FL
34787-6042
US

IV. Provider business mailing address

579 CALIBRE CREST PKWY APT 204
ALTAMONTE SPRINGS FL
32714-3635
US

V. Phone/Fax

Practice location:
  • Phone: 407-877-2394
  • Fax:
Mailing address:
  • Phone: 407-484-6708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberPTA22746
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: