Provider Demographics
NPI:1043581010
Name:JANZEN, CARLOS JESUS (PTA)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:JESUS
Last Name:JANZEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:579 CALIBRE CREST PKWY APT 204
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-3635
Mailing Address - Country:US
Mailing Address - Phone:407-484-6708
Mailing Address - Fax:
Practice Address - Street 1:15204 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-6042
Practice Address - Country:US
Practice Address - Phone:407-877-2394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22746314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility