Provider Demographics
NPI:1457902256
Name:ENCINO PARK FAMILY HEALTH & WELLNESS CLINIC
Entity Type:Organization
Organization Name:ENCINO PARK FAMILY HEALTH & WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:210-568-5816
Mailing Address - Street 1:PO BOX 53666
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79710-3666
Mailing Address - Country:US
Mailing Address - Phone:210-568-5816
Mailing Address - Fax:210-399-4637
Practice Address - Street 1:13423 BLANCO RD # 8046
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-2187
Practice Address - Country:US
Practice Address - Phone:210-568-5816
Practice Address - Fax:210-399-4637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-23
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty