MEDICARE: MR. DAVID CHARLES LEIDNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	A1122001	CA

General Provider Information

NPI Number	:	1003165143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID CHARLES LEIDNER

Provider Business Mailing Address
First Line	:	1308 FACTORY PL
Second Line	:	#404
City	:	LOS ANGELES
State	:	CA
Zip	:	90013-2252
Country	:	US
Telephone Number	:	213-973-7670
Fax Number	:

Provider Business Practice Location Address
First Line	:	1308 FACTORY PL
Second Line	:	#404
City	:	LOS ANGELES
State	:	CA
Zip	:	90013-2252
Country	:	US
Telephone Number	:	213-973-7670
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2012
Last Update Date	:	09/05/2012

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