Healthcare Provider Details

I. General information

NPI: 1548197700
Provider Name (Legal Business Name): GERRICK FLOYD CHAN DE LEON MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1565 BAILEY AVE
EDWARDS CA
93523-1513
US

IV. Provider business mailing address

17100 FOOTHILL AVE
NORTH EDWARDS CA
93523-3533
US

V. Phone/Fax

Practice location:
  • Phone: 760-306-4991
  • Fax:
Mailing address:
  • Phone: 760-769-4821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP26493
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: