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NPI Code Detail

MEDICARE: MR. JOHNNY LEE LEBORD M.P.

MEDICARE: MR. JOHNNY LEE LEBORD M.P.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1174400000XSpecialistMA00015163WA

General Provider Information

NPI Number : 1659584001
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JOHNNY LEE LEBORD M.P.
Provider Business Mailing Address
First Line : 15539 MERIDIAN AVE N
Second Line :
City : SHORELINE
State : WA
Zip : 98133-6038
Country : US
Telephone Number : 206-755-0008
Fax Number : 206-933-6088
Provider Business Practice Location Address
First Line : 9001 35TH AVE SW
Second Line :
City : SEATTLE
State : WA
Zip : 98126-3820
Country : US
Telephone Number : 206-755-0008
Fax Number : 206-933-6088
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/08/2007
Last Update Date : 07/08/2007

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