Healthcare Provider Details

I. General information

NPI: 1295266500
Provider Name (Legal Business Name): JAY DE LEON CARIZON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 IRVINE AVE #116
COSTA MESA CA
92627-4653
US

IV. Provider business mailing address

429 E 1ST ST
TUSTIN CA
92780-3311
US

V. Phone/Fax

Practice location:
  • Phone: 949-631-0200
  • Fax:
Mailing address:
  • Phone: 760-408-3993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number48626
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: