Healthcare Provider Details

I. General information

NPI: 1710720719
Provider Name (Legal Business Name): JALEEL ANJELO LEYCO CUASAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 SW WILSHIRE BLVD STE B
BURLESON TX
76028-5300
US

IV. Provider business mailing address

437 SW WILSHIRE BLVD STE B
BURLESON TX
76028-5300
US

V. Phone/Fax

Practice location:
  • Phone: 817-904-5070
  • Fax: 817-916-0879
Mailing address:
  • Phone: 817-904-5070
  • Fax: 817-916-0879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1391711
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: