Healthcare Provider Details

I. General information

NPI: 1598506446
Provider Name (Legal Business Name): ANTONIO LYDELL PERCY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 DEL HOMBRE LN APT 201
WALNUT CREEK CA
94597-2297
US

IV. Provider business mailing address

3050 DEL HOMBRE LN APT 201
WALNUT CREEK CA
94597-2297
US

V. Phone/Fax

Practice location:
  • Phone: 423-902-5094
  • Fax:
Mailing address:
  • Phone: 423-902-5094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: