Basic Information
| Provider Information | |||||||||
| NPI: | 1255588976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELEON | ||||||||
| FirstName: | OMAR | ||||||||
| MiddleName: | MIKE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5957 S MOONEY BLVD | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932779394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597374660 | ||||||||
| FaxNumber: | 5597374697 | ||||||||
| Practice Location | |||||||||
| Address1: | 11200 AVENUE 368 | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932918940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597133285 | ||||||||
| FaxNumber: | 5597133296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2008 | ||||||||
| LastUpdateDate: | 08/25/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.