Provider Demographics
NPI:1568828986
Name:DE LEON, ANGELITO BUSTAMANTE (PT)
Entity Type:Individual
Prefix:
First Name:ANGELITO
Middle Name:BUSTAMANTE
Last Name:DE LEON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13178 ALTA VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-3461
Mailing Address - Country:US
Mailing Address - Phone:818-731-3293
Mailing Address - Fax:
Practice Address - Street 1:13178 ALTA VISTA WAY
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-3461
Practice Address - Country:US
Practice Address - Phone:818-731-3293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33282225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist