Healthcare Provider Details

I. General information

NPI: 1124583299
Provider Name (Legal Business Name): LETICIA FLORES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 JENKS DR
CORONA CA
92880
US

IV. Provider business mailing address

391 JENKS DR
CORONA CA
92880-2518
US

V. Phone/Fax

Practice location:
  • Phone: 949-922-5988
  • Fax:
Mailing address:
  • Phone: 435-680-9236
  • Fax: 949-396-1154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: