Healthcare Provider Details

I. General information

NPI: 1073360723
Provider Name (Legal Business Name): MR. JOSE MANUEL HERNANDEZ II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 05/01/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 BROADWAY STE 301
TACOMA WA
98402-4454
US

IV. Provider business mailing address

4706 CALDWELL RD E
EDGEWOOD WA
98372-9221
US

V. Phone/Fax

Practice location:
  • Phone: 253-671-9909
  • Fax:
Mailing address:
  • Phone: 360-927-6758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberCB61550345
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: