MEDICARE: JOSE CARLOS LA O PUENTES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		FL

General Provider Information

NPI Number	:	1114706041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE CARLOS LA O PUENTES

Provider Business Mailing Address
First Line	:	1710 SE 21ST ST
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-4122
Country	:	US
Telephone Number	:	239-745-9324
Fax Number	:

Provider Business Practice Location Address
First Line	:	1710 SE 21ST ST
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-4122
Country	:	US
Telephone Number	:	239-745-9324
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2023
Last Update Date	:	09/28/2023

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Directions to “ JOSE CARLOS LA O PUENTES ” Practice Location

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