=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750730081
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIMMY JIMENEZ D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2016
-----------------------------------------------------
Last Update Date | 11/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 717 S AVERILL AVE
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90732-3813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-732-3012
-----------------------------------------------------
Fax | 424-232-8502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 717 S AVERILL AVE
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-732-3002
-----------------------------------------------------
Fax | 424-232-8502
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NN1001X
-----------------------------------------------------
Taxonomy Name | Nutrition Chiropractor
-----------------------------------------------------
License Number | 33600
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 33600
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 33600
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------