Provider Demographics
NPI:1497549869
Name:VIDALES, IRMA LETICIA
Entity type:Individual
Prefix:
First Name:IRMA
Middle Name:LETICIA
Last Name:VIDALES
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E VANDERBILT WAY
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0026
Mailing Address - Country:US
Mailing Address - Phone:888-743-1478
Mailing Address - Fax:
Practice Address - Street 1:17053 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3574
Practice Address - Country:US
Practice Address - Phone:909-347-1341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker