Healthcare Provider Details

I. General information

NPI: 1871011908
Provider Name (Legal Business Name): LARRY LEE LEONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30116 EIGENBRODT WAY
UNION CITY CA
94587
US

IV. Provider business mailing address

30116 EIGENBRODT WAY
UNION CITY CA
94587-1225
US

V. Phone/Fax

Practice location:
  • Phone: 510-826-6299
  • Fax:
Mailing address:
  • Phone: 510-826-6299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number29473
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: