Healthcare Provider Details

I. General information

NPI: 1760094445
Provider Name (Legal Business Name): CONSTANCE LEAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2020
Last Update Date: 08/23/2020
Certification Date: 08/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2841 MARTIN LUTHER KING JR AVE
RICHMOND CA
94804-4021
US

IV. Provider business mailing address

2841 MARTIN LUTHER KING JR AVE
RICHMOND CA
94804-4021
US

V. Phone/Fax

Practice location:
  • Phone: 855-883-7325
  • Fax:
Mailing address:
  • Phone: 855-883-7325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number615965
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: