Provider Demographics
NPI:1063191021
Name:MIRALLES, FIDEL OMLANG SR
Entity type:Individual
Prefix:
First Name:FIDEL
Middle Name:OMLANG
Last Name:MIRALLES
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 LA JOLLA VILLAGE DR STE 100-200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-4601
Mailing Address - Country:US
Mailing Address - Phone:619-253-8951
Mailing Address - Fax:
Practice Address - Street 1:4660 LA JOLLA VILLAGE DR STE 100-200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-4601
Practice Address - Country:US
Practice Address - Phone:619-253-8951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54036932278P4000X, 2279P4000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No2278P4000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedPatient Transport
No2279P4000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPatient Transport