Healthcare Provider Details

I. General information

NPI: 1306592118
Provider Name (Legal Business Name): JORGE DAVID CUENCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 MAIN ST
SPRINGFIELD MA
01104-3301
US

IV. Provider business mailing address

147 NORMAN ST
WEST SPRINGFIELD MA
01089-5003
US

V. Phone/Fax

Practice location:
  • Phone: 413-736-0395
  • Fax: 413-732-5362
Mailing address:
  • Phone: 413-296-6185
  • Fax: 413-732-5362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: