Provider Demographics
NPI:1457961948
Name:TOLENTINO, LIBERTY MIGUEL
Entity Type:Individual
Prefix:
First Name:LIBERTY
Middle Name:MIGUEL
Last Name:TOLENTINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 CARLOS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4607
Mailing Address - Country:US
Mailing Address - Phone:619-263-1287
Mailing Address - Fax:
Practice Address - Street 1:446 ALTA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92158-0001
Practice Address - Country:US
Practice Address - Phone:619-661-6551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-09
Last Update Date:2020-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA514651163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse