Healthcare Provider Details

I. General information

NPI: 1609112077
Provider Name (Legal Business Name): ANTHONY RAYMOND FIDEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ANTHONY LECHUGA

II. Dates (important events)

Enumeration Date: 12/12/2012
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25588 MAITLAND DR
HAYWARD CA
94542-1823
US

IV. Provider business mailing address

25588 MAITLAND DR
HAYWARD CA
94542-1823
US

V. Phone/Fax

Practice location:
  • Phone: 510-921-2532
  • Fax:
Mailing address:
  • Phone: 510-921-2532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number829477
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: