Healthcare Provider Details

I. General information

NPI: 1871784413
Provider Name (Legal Business Name): JULIO MANUEL THILLET LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8115 164TH ST
JAMAICA NY
11432-1118
US

IV. Provider business mailing address

725 E 230TH ST
BRONX NY
10466-4103
US

V. Phone/Fax

Practice location:
  • Phone: 718-380-3000
  • Fax: 718-969-5857
Mailing address:
  • Phone: 718-380-3000
  • Fax: 718-969-5857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number5310583
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: