Healthcare Provider Details

I. General information

NPI: 1629863733
Provider Name (Legal Business Name): SAMUEL GREENLEAF PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SAMUEL HART

II. Dates (important events)

Enumeration Date: 04/10/2025
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25864 BUSINESS CENTER DR STE C
REDLANDS CA
92374-4515
US

IV. Provider business mailing address

25864 BUSINESS CENTER DR STE C
REDLANDS CA
92374-4515
US

V. Phone/Fax

Practice location:
  • Phone: 909-796-7700
  • Fax: 909-796-4384
Mailing address:
  • Phone: 909-796-7700
  • Fax: 909-796-4384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number306672
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: