MEDICARE: MR. LEONARDO ESTEBAN NOGUERA JIMENEZ ITDS

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	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1275394231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEONARDO ESTEBAN NOGUERA JIMENEZ ITDS

Provider Business Mailing Address
First Line	:	641 CYPRESS LAKE BLVD APT K
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33064-5088
Country	:	US
Telephone Number	:	954-940-0035
Fax Number	:

Provider Business Practice Location Address
First Line	:	641 CYPRESS LAKE BLVD APT K
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33064-5088
Country	:	US
Telephone Number	:	954-940-0035
Fax Number	:

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

Provider Enumeration Date	:	01/17/2024
Last Update Date	:	01/17/2024

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