Provider Demographics
NPI:1770279911
Name:ROA GIMENEZ, HORACIO R (CMT)
Entity type:Individual
Prefix:
First Name:HORACIO
Middle Name:R
Last Name:ROA GIMENEZ
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 684
Mailing Address - Street 2:
Mailing Address - City:OREGON HOUSE
Mailing Address - State:CA
Mailing Address - Zip Code:95962-0684
Mailing Address - Country:US
Mailing Address - Phone:530-790-5167
Mailing Address - Fax:
Practice Address - Street 1:13376 RUE MONTAIGNE
Practice Address - Street 2:
Practice Address - City:OREGON HOUSE
Practice Address - State:CA
Practice Address - Zip Code:95962-0684
Practice Address - Country:US
Practice Address - Phone:530-790-5167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
509711225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist