=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851064695
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY STANSBERRY LE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2021
-----------------------------------------------------
Last Update Date | 07/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 855 MAIN ST STE 210
-----------------------------------------------------
City | PLEASANTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94566-6650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-399-1425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 855 MAIN ST STE 210
-----------------------------------------------------
City | PLEASANTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94566-6650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-399-1425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | L9689
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------