Provider Demographics
NPI:1376644245
Name:DE LEON, JUAN MANUEL (LSA-C/ROT)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:MANUEL
Last Name:DE LEON
Suffix:
Gender:M
Credentials:LSA-C/ROT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 COMFORT DR
Mailing Address - Street 2:
Mailing Address - City:SAN BENITO
Mailing Address - State:TX
Mailing Address - Zip Code:78586-2719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:890 COMFORT DR
Practice Address - Street 2:
Practice Address - City:SAN BENITO
Practice Address - State:TX
Practice Address - Zip Code:78586-2719
Practice Address - Country:US
Practice Address - Phone:956-491-6905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00117246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist