=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730643982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARLEY LEON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2019
-----------------------------------------------------
Last Update Date | 02/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1255 W COLTON AVE SPC 600
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92374-2861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-571-1852
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1255 W COLTON AVE SPC 600
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92374-2861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-571-1852
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPTICIAN
-----------------------------------------------------
Name | MARLEY LEON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-571-1852
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------