Healthcare Provider Details

I. General information

NPI: 1730643982
Provider Name (Legal Business Name): MARLEY LEON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 W COLTON AVE SPC 600
REDLANDS CA
92374-2861
US

IV. Provider business mailing address

1255 W COLTON AVE SPC 600
REDLANDS CA
92374-2861
US

V. Phone/Fax

Practice location:
  • Phone: 909-571-1852
  • Fax:
Mailing address:
  • Phone: 909-571-1852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: MARLEY LEON
Title or Position: OWNER/OPTICIAN
Credential:
Phone: 909-571-1852