Provider Demographics
NPI:1427338227
Name:REBOLLO, JUAN CARLOS II (CNA)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:CARLOS
Last Name:REBOLLO
Suffix:II
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 PROSPECT STREET
Mailing Address - Street 2:APARTMENT A6
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-3045
Mailing Address - Country:US
Mailing Address - Phone:860-218-7027
Mailing Address - Fax:
Practice Address - Street 1:38 PROSPECT ST.
Practice Address - Street 2:APARTMENT A6
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-3045
Practice Address - Country:US
Practice Address - Phone:860-218-7027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTNA99888123747A0650X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider