Healthcare Provider Details

I. General information

NPI: 1508017708
Provider Name (Legal Business Name): LEODEGARD DYOCO R.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5878 BACKUS PEAK WAY
FONTANA CA
92336-4584
US

IV. Provider business mailing address

5878 BACKUS PEAK WAY
FONTANA CA
92336-4584
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-0693
  • Fax:
Mailing address:
  • Phone: 909-427-0693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 28803
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: