Provider Demographics
NPI:1124886320
Name:BALAGTAS, ODESSIE JANE CICERON
Entity type:Individual
Prefix:
First Name:ODESSIE JANE
Middle Name:CICERON
Last Name:BALAGTAS
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 1:277 BLOOMINGTON AVE UNIT 225
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-6495
Mailing Address - Country:US
Mailing Address - Phone:909-600-9979
Mailing Address - Fax:
Practice Address - Street 1:150 W ROUTE 66
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6207
Practice Address - Country:US
Practice Address - Phone:626-852-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA765151163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse