Provider Demographics
NPI:1306298013
Name:VILLARRUEL, JOSE P
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:P
Last Name:VILLARRUEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3590 JUBILANT PL
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-2513
Mailing Address - Country:US
Mailing Address - Phone:719-491-0691
Mailing Address - Fax:719-591-2140
Practice Address - Street 1:3590 JUBILANT PL
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-2513
Practice Address - Country:US
Practice Address - Phone:719-491-0691
Practice Address - Fax:719-591-2140
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21547171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58689559Medicaid