Provider Demographics
NPI:1245649607
Name:PEDRIQUE, HENRY JOSE (MBA)
Entity type:Individual
Prefix:MR
First Name:HENRY
Middle Name:JOSE
Last Name:PEDRIQUE
Suffix:
Gender:M
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6956 W SAMPLE RD
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-4284
Mailing Address - Country:US
Mailing Address - Phone:954-993-0874
Mailing Address - Fax:
Practice Address - Street 1:6956 W SAMPLE RD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-4284
Practice Address - Country:US
Practice Address - Phone:954-993-0874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-10
Last Update Date:2014-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP230513171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor