Provider Demographics
NPI:1912291675
Name:MAGDALENO, LETICIA (BA)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:MAGDALENO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 S BENSON AVE
Mailing Address - Street 2:#4
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-6902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1460 E HOLT AVE
Practice Address - Street 2:#8
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5856
Practice Address - Country:US
Practice Address - Phone:909-865-0599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-30
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner