Healthcare Provider Details

I. General information

NPI: 1366431959
Provider Name (Legal Business Name): DEKRO, A MEDICAL CORPORATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4002 VISTA WAY
OCEANSIDE CA
92056-4506
US

IV. Provider business mailing address

3156 VISTA WAY SUITE 405
OCEANSIDE CA
92056-3622
US

V. Phone/Fax

Practice location:
  • Phone: 760-439-6581
  • Fax: 760-439-6585
Mailing address:
  • Phone: 760-439-6581
  • Fax: 760-439-6585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: JUAN DEZA
Title or Position: DIRECTOR
Credential: M.D.
Phone: 760-439-6581