MEDICARE: JAIME ALBERTO CANTILLO ENAMORADO

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	BACB1030600	FL

General Provider Information

NPI Number	:	1861263832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAIME ALBERTO CANTILLO ENAMORADO

Provider Business Mailing Address
First Line	:	4424 SUSSEX AVE
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-1739
Country	:	US
Telephone Number	:	561-764-8827
Fax Number	:

Provider Business Practice Location Address
First Line	:	4424 SUSSEX AVE
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-1739
Country	:	US
Telephone Number	:	561-764-8827
Fax Number	:

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

Provider Enumeration Date	:	01/09/2024
Last Update Date	:	01/09/2024

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