MEDICARE: MISS ANNETTE P LEON PT

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	225100000X	Physical Therapist	3102	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OPT 287010	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1164424206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ANNETTE P LEON PT

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:	630-296-2223
Fax Number	:	630-759-9510

Provider Business Practice Location Address
First Line	:	3175 SAINT ROSE PKWY
Second Line	:	STE 331
City	:	HENDERSON
State	:	NV
Zip	:	89052-3506
Country	:	US
Telephone Number	:	702-474-7212
Fax Number	:

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	09/21/2016

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