Healthcare Provider Details

I. General information

NPI: 1366783227
Provider Name (Legal Business Name): GREGORY LEGGETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 N LAKE AVE
PASADENA CA
91104-4521
US

IV. Provider business mailing address

251 N CRAIG AVE APT#2
PASADENA CA
91107-3201
US

V. Phone/Fax

Practice location:
  • Phone: 626-808-9746
  • Fax:
Mailing address:
  • Phone: 323-718-3653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: