Healthcare Provider Details

I. General information

NPI: 1376889832
Provider Name (Legal Business Name): MARLA G LEGER HIS/HAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2013
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 SPRING LAKE SQ
WINTER HAVEN FL
33881-1338
US

IV. Provider business mailing address

816 SPRING LAKE SQ
WINTER HAVEN FL
33881-1338
US

V. Phone/Fax

Practice location:
  • Phone: 863-293-0703
  • Fax: 863-293-0815
Mailing address:
  • Phone: 863-293-0703
  • Fax: 863-293-0815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS-4773
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: