1316406218 NPI number — LESLIE MARICE DE LOS SANTOS DO

Table of content: LESLIE MARICE DE LOS SANTOS DO (NPI 1316406218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316406218 NPI number — LESLIE MARICE DE LOS SANTOS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LOS SANTOS
Provider First Name:
LESLIE
Provider Middle Name:
MARICE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
LESLIE
Provider Other Middle Name:
MARICE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316406218
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 UNIVERSITY DR E STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGE STATION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77840-2600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-383-2358
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1602 ROCK PRAIRIE RD STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLEGE STATION
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77845-8309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-693-7400
Provider Business Practice Location Address Fax Number:
979-693-2845
Provider Enumeration Date:
03/19/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  T4333 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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