Provider Demographics
NPI:1548768963
Name:VIDAL, LEANDRO AARON
Entity Type:Individual
Prefix:
First Name:LEANDRO
Middle Name:AARON
Last Name:VIDAL
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 1:2344 GREENBRIAR DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-1119
Mailing Address - Country:US
Mailing Address - Phone:619-708-5003
Mailing Address - Fax:
Practice Address - Street 1:625 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4321
Practice Address - Country:US
Practice Address - Phone:858-603-4812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician