Provider Demographics
NPI:1194921882
Name:ZACARIAS, LESLIE REGINIO
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:REGINIO
Last Name:ZACARIAS
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 1:13474 RAMONA PKWY
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3944
Mailing Address - Country:US
Mailing Address - Phone:626-374-9811
Mailing Address - Fax:626-472-6650
Practice Address - Street 1:11926 LA MIRADA BLVD
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1303
Practice Address - Country:US
Practice Address - Phone:562-943-7156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28299314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility