Healthcare Provider Details

I. General information

NPI: 1760166193
Provider Name (Legal Business Name): LESLEY VIDAURI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 W REDONDO BEACH BLVD
GARDENA CA
90247-4128
US

IV. Provider business mailing address

1045 W REDONDO BEACH BLVD
GARDENA CA
90247-4128
US

V. Phone/Fax

Practice location:
  • Phone: 310-553-2695
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number7349
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: