Healthcare Provider Details

I. General information

NPI: 1003786633
Provider Name (Legal Business Name): HERLYN MCINTOSCH LEIVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2025
Last Update Date: 11/08/2025
Certification Date: 11/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23119 SOBOBA RD
SAN JACINTO CA
92583-2904
US

IV. Provider business mailing address

23945 PICO AVE
MENIFEE CA
92585-9549
US

V. Phone/Fax

Practice location:
  • Phone: 951-654-0803
  • Fax:
Mailing address:
  • Phone: 951-220-5905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number36096
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: