=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003693532
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORE JIMENEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2023
-----------------------------------------------------
Last Update Date | 09/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1810 THRELKEL ST
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89512-3713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-325-8297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11620 CLAIM STAKE DR
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89506-7529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-340-6326
-----------------------------------------------------
Fax | 775-525-2426
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------