Healthcare Provider Details

I. General information

NPI: 1710297817
Provider Name (Legal Business Name): LESLEY CUSTODIO L.AC., DACM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 S MAGNOLIA AVE
EL CAJON CA
92020-5211
US

IV. Provider business mailing address

314 S MAGNOLIA AVE
EL CAJON CA
92020-5211
US

V. Phone/Fax

Practice location:
  • Phone: 619-438-0228
  • Fax: 619-436-4739
Mailing address:
  • Phone: 619-438-0228
  • Fax: 619-436-4739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC13851
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: