Healthcare Provider Details

I. General information

NPI: 1861787871
Provider Name (Legal Business Name): TRAVIS WILLIAM LEONG PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2011
Last Update Date: 10/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E LAMBERT RD SUITE 220
BREA CA
92821-4370
US

IV. Provider business mailing address

1800 E LAMBERT RD SUITE 220
BREA CA
92821-4370
US

V. Phone/Fax

Practice location:
  • Phone: 714-256-5074
  • Fax: 714-256-0770
Mailing address:
  • Phone: 714-256-5074
  • Fax: 714-256-0770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8722
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number41731
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: