Healthcare Provider Details

I. General information

NPI: 1457638710
Provider Name (Legal Business Name): FRANCIS LEROY PICKLESIMER II DMT IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 TARAWA RD
SAN DIEGO CA
92155-5198
US

IV. Provider business mailing address

15698 CONCORD RIDGE TER
SAN DIEGO CA
92127-4157
US

V. Phone/Fax

Practice location:
  • Phone: 619-437-5393
  • Fax: 619-437-5319
Mailing address:
  • Phone: 858-349-4568
  • Fax: 619-437-5319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: