Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223G0001X | General Practice | 13691 | CA |
N | 213EG0000X | General Practice | 13691 | CA |
Y | 1223G0001X | General Practice | 23523 | CA |
Y | 213EG0000X | General Practice | 23523 | CA |
NPI | 1003951864 |
---|---|
Provider Name | Bernard Lagelle Jeter SR. |
First Address | Visalia, CA 93291 |
Second Address | Visalia, CA 93291 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/02/2007 |
Last Update Date | 06/10/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
862543 | UNITED CONCORDIA (01) | CA |
B 23523 01 | DENTICAL (01) | CA |