Provider Demographics
NPI:1225612922
Name:HACKLER, DE'RON
Entity type:Individual
Prefix:
First Name:DE'RON
Middle Name:
Last Name:HACKLER
Suffix:
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 1:1400 13TH ST APT 216
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-3721
Mailing Address - Country:US
Mailing Address - Phone:619-942-7070
Mailing Address - Fax:
Practice Address - Street 1:3132 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4421
Practice Address - Country:US
Practice Address - Phone:619-683-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-09
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator