Provider Demographics
NPI:1043669872
Name:BAZO JACOMINO, ENAY MANUEL
Entity type:Individual
Prefix:
First Name:ENAY
Middle Name:MANUEL
Last Name:BAZO JACOMINO
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 1:19801 SW 110TH CT APT 220
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-8448
Mailing Address - Country:US
Mailing Address - Phone:305-764-1458
Mailing Address - Fax:
Practice Address - Street 1:19801 SW 110TH CT APT 220
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-8448
Practice Address - Country:US
Practice Address - Phone:305-764-1458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst