Provider Demographics
NPI:1215007695
Name:QUANTOM-LEAP, INC.
Entity type:Organization
Organization Name:QUANTOM-LEAP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-244-1789
Mailing Address - Street 1:7299 N CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-0487
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22368 SOUTH 6TH STREET
Practice Address - Street 2:
Practice Address - City:DOS PALOS
Practice Address - State:CA
Practice Address - Zip Code:93665
Practice Address - Country:US
Practice Address - Phone:559-244-1789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA24004APOtherMEDI-CAL PROVIDER NUMBER