Healthcare Provider Details

I. General information

NPI: 1649101676
Provider Name (Legal Business Name): HEENAM LEEM DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 INDIANA AVE STE 1
RIVERSIDE CA
92503-5498
US

IV. Provider business mailing address

9900 INDIANA AVE STE 1
RIVERSIDE CA
92503-5498
US

V. Phone/Fax

Practice location:
  • Phone: 951-376-1120
  • Fax: 951-376-1182
Mailing address:
  • Phone: 951-376-1120
  • Fax: 951-376-1182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT309917
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: