Provider Demographics
NPI:1427651082
Name:BOMBALE ROJAS, JOSE ANTONIO
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:ANTONIO
Last Name:BOMBALE ROJAS
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 1:2217 SW 8TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-3662
Mailing Address - Country:US
Mailing Address - Phone:336-804-2778
Mailing Address - Fax:
Practice Address - Street 1:2217 SW 8TH PL
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-3662
Practice Address - Country:US
Practice Address - Phone:336-804-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-125715106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician