Provider Demographics
NPI:1194217182
Name:DE LEON, JUSTIN CLARINO
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CLARINO
Last Name:DE LEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 HAMER DR
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-2123
Mailing Address - Country:US
Mailing Address - Phone:714-851-4904
Mailing Address - Fax:
Practice Address - Street 1:101 E VALENCIA MESA DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3809
Practice Address - Country:US
Practice Address - Phone:714-992-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95117571163W00000X, 163WM0705X, 163WX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WX0800XNursing Service ProvidersRegistered NurseOrthopedic