Healthcare Provider Details

I. General information

NPI: 1316418551
Provider Name (Legal Business Name): LEADING EDGE INNOVATIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 MOBIL AVE
CAMARILLO CA
93010-6315
US

IV. Provider business mailing address

699 MOBIL AVE
CAMARILLO CA
93010-6315
US

V. Phone/Fax

Practice location:
  • Phone: 805-388-7669
  • Fax: 805-389-8142
Mailing address:
  • Phone: 805-388-7669
  • Fax: 805-389-8142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. PAUL DWORK
Title or Position: PRESIDENT
Credential: PHARM.D.
Phone: 805-388-7669