Provider Demographics
NPI:1750092961
Name:LEON, SOCORRO S
Entity type:Individual
Prefix:
First Name:SOCORRO
Middle Name:S
Last Name:LEON
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 1:5225 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-4113
Mailing Address - Country:US
Mailing Address - Phone:805-765-6495
Mailing Address - Fax:
Practice Address - Street 1:5225 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-4113
Practice Address - Country:US
Practice Address - Phone:805-765-6495
Practice Address - Fax:805-765-6490
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA210323164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1619340155Medicaid