Healthcare Provider Details

I. General information

NPI: 1134089782
Provider Name (Legal Business Name): JAVIER CESAR LEAL-CRUZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 11/17/2025
Certification Date: 11/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12229 JOBEL LN
BROADWAY VA
22815-3100
US

IV. Provider business mailing address

12229 JOBEL LN
BROADWAY VA
22815-3100
US

V. Phone/Fax

Practice location:
  • Phone: 540-746-5035
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: