Provider Demographics
NPI:1215957139
Name:CLETO, CONSTANCIO L (MT)
Entity type:Individual
Prefix:MR
First Name:CONSTANCIO
Middle Name:L
Last Name:CLETO
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:LAPWAI
Mailing Address - State:ID
Mailing Address - Zip Code:83540-0367
Mailing Address - Country:US
Mailing Address - Phone:208-843-2271
Mailing Address - Fax:208-843-2658
Practice Address - Street 1:111 BEVER GRADE
Practice Address - Street 2:
Practice Address - City:LAPWAI
Practice Address - State:ID
Practice Address - Zip Code:83540
Practice Address - Country:US
Practice Address - Phone:208-843-2271
Practice Address - Fax:208-843-2658
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMT172684-02645309246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory