Healthcare Provider Details

I. General information

NPI: 1164243242
Provider Name (Legal Business Name): LEONARD M FLYNN SUDRC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2575 DEPOT RD
HAYWARD CA
94545-2341
US

IV. Provider business mailing address

2575 DEPOT RD
HAYWARD CA
94545-2341
US

V. Phone/Fax

Practice location:
  • Phone: 510-784-5874
  • Fax: 510-784-5874
Mailing address:
  • Phone: 510-784-5874
  • Fax: 510-784-5874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19351
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: