Healthcare Provider Details

I. General information

NPI: 1487691168
Provider Name (Legal Business Name): LEONARD STAVROPOLSKIY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10100 JAMISON AVE STE 222
PHILADELPHIA PA
19116-3832
US

IV. Provider business mailing address

10100 JAMISON AVE STE 222
PHILADELPHIA PA
19116-3832
US

V. Phone/Fax

Practice location:
  • Phone: 215-676-3870
  • Fax: 215-676-6856
Mailing address:
  • Phone: 215-676-3870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC007444L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT015799
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: