Provider Demographics
NPI:1972340669
Name:HERNANDEZ, LOUIS V JR
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:V
Last Name:HERNANDEZ
Suffix:JR
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 1:120 E SAGUARO ST
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-2534
Mailing Address - Country:US
Mailing Address - Phone:520-560-0045
Mailing Address - Fax:
Practice Address - Street 1:120 E SAGUARO ST
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-2534
Practice Address - Country:US
Practice Address - Phone:520-560-0045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBL-23-59964172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver