Provider Demographics
NPI:1982889804
Name:LEOPOLDO E VALDIVIA DO
Entity Type:Organization
Organization Name:LEOPOLDO E VALDIVIA DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:VALDIVIA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:559-686-3311
Mailing Address - Street 1:1068 N CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274
Mailing Address - Country:US
Mailing Address - Phone:559-686-3311
Mailing Address - Fax:559-686-3363
Practice Address - Street 1:1068 N CHERRY ST
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274
Practice Address - Country:US
Practice Address - Phone:559-686-3311
Practice Address - Fax:559-686-3363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLM 29020291U00000X
CA20A7040291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB98288FMedicaid
CAG63913Medicare UPIN