Healthcare Provider Details

I. General information

NPI: 1871223404
Provider Name (Legal Business Name): FREDERICO JIMENEZ LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 E 3RD ST
NEW YORK NY
10003-8908
US

IV. Provider business mailing address

77 COLUMBIA ST APT 4A
NEW YORK NY
10002-2610
US

V. Phone/Fax

Practice location:
  • Phone: 212-620-0340
  • Fax: 212-533-8400
Mailing address:
  • Phone: 646-956-9172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number336371
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: