Provider Demographics
NPI:1245603265
Name:YEDOR, LESLIE (LAC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:YEDOR
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5021 VERDUGO WAY STE 105-177
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8675
Mailing Address - Country:US
Mailing Address - Phone:805-338-6905
Mailing Address - Fax:
Practice Address - Street 1:5021 VERDUGO WAY STE 105-177
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8675
Practice Address - Country:US
Practice Address - Phone:805-338-6905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC16735171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist