=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740732205
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEA FAJARDO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2016
-----------------------------------------------------
Last Update Date | 11/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6512 YOUNGSTOWN ST
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91710-6948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-529-4628
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6512 YOUNGSTOWN ST
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91710-6948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 34935
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------