Healthcare Provider Details

I. General information

NPI: 1194921882
Provider Name (Legal Business Name): LESLIE REGINIO ZACARIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11926 LA MIRADA BLVD
LA MIRADA CA
90638-1303
US

IV. Provider business mailing address

13474 RAMONA PKWY
BALDWIN PARK CA
91706-3944
US

V. Phone/Fax

Practice location:
  • Phone: 562-943-7156
  • Fax:
Mailing address:
  • Phone: 626-374-9811
  • Fax: 626-472-6650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberPT28299
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: