MEDICARE: MARCUS VON LEONARD CERTIFIED HAIR LOSS

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
1	1744P3200X	Prosthetics Case Management

General Provider Information

NPI Number	:	1932621257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCUS VON LEONARD CERTIFIED HAIR LOSS

Provider Business Mailing Address
First Line	:	11200 BROADWAY ST.
Second Line	:	SUITE #1410
City	:	PEARLAND
State	:	TX
Zip	:	77584
Country	:	US
Telephone Number	:	832-265-3766
Fax Number	:

Provider Business Practice Location Address
First Line	:	11200 BROADWAY ST.
Second Line	:	SUITE #1410
City	:	PEARLAND
State	:	TX
Zip	:	77584
Country	:	US
Telephone Number	:	832-265-3766
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2017
Last Update Date	:	07/07/2017

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