Healthcare Provider Details

I. General information

NPI: 1871253930
Provider Name (Legal Business Name): BRICE LEION PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 12/30/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SW KINKADE RD
BOARDMAN OR
97818-9001
US

IV. Provider business mailing address

PO BOX 70689
SALT LAKE CITY UT
84170-0689
US

V. Phone/Fax

Practice location:
  • Phone: 541-481-2533
  • Fax:
Mailing address:
  • Phone: 801-987-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number64336
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: