Healthcare Provider Details

I. General information

NPI: 1790404382
Provider Name (Legal Business Name): CARLOS ANDRES LEON SUDCC II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 BUSINESS CENTER DR
FAIRFIELD CA
94534-1696
US

IV. Provider business mailing address

1621 LOUISIANA ST
VALLEJO CA
94590-4744
US

V. Phone/Fax

Practice location:
  • Phone: 707-224-8266
  • Fax:
Mailing address:
  • Phone: 369-217-1123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number7289
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: