Provider Demographics
NPI:1578387296
Name:FRUITS, MAX JOSE
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:JOSE
Last Name:FRUITS
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 1:1375 WINDMILL LN
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-3268
Mailing Address - Country:US
Mailing Address - Phone:216-954-0954
Mailing Address - Fax:
Practice Address - Street 1:1375 WINDMILL LN
Practice Address - Street 2:
Practice Address - City:BROADVIEW HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44147-3268
Practice Address - Country:US
Practice Address - Phone:216-954-0954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-09
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHVN593674172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver