Healthcare Provider Details

I. General information

NPI: 1225612922
Provider Name (Legal Business Name): DE'RON HACKLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2021
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3132 JEFFERSON ST
SAN DIEGO CA
92110-4421
US

IV. Provider business mailing address

1400 13TH ST APT 216
IMPERIAL BEACH CA
91932-3721
US

V. Phone/Fax

Practice location:
  • Phone: 619-683-3100
  • Fax:
Mailing address:
  • Phone: 619-942-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: