Healthcare Provider Details

I. General information

NPI: 1154011302
Provider Name (Legal Business Name): LEOBARDO REYES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12047 STEWARTON DR
PORTER RANCH CA
91326-1156
US

IV. Provider business mailing address

12047 STEWARTON DR
PORTER RANCH CA
91326-1156
US

V. Phone/Fax

Practice location:
  • Phone: 818-640-4039
  • Fax: 818-640-4039
Mailing address:
  • Phone: 818-640-4039
  • Fax: 818-640-4039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA5374
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: