Provider Demographics
NPI:1053197160
Name:HENARES, JUAN FIDEL SANTIAGO (LMT)
Entity type:Individual
Prefix:
First Name:JUAN FIDEL
Middle Name:SANTIAGO
Last Name:HENARES
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:JOHN FIDEL
Other - Middle Name:SANTIAGO
Other - Last Name:HENARES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:2402 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-3229
Mailing Address - Country:US
Mailing Address - Phone:360-605-2221
Mailing Address - Fax:
Practice Address - Street 1:2402 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3229
Practice Address - Country:US
Practice Address - Phone:360-246-6630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61480559225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist