MEDICARE: DR. JONATHAN LEARY DC

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	111NS0005X	Sports Physician Chiropractor	33497	CA

General Provider Information

NPI Number	:	1225498124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN LEARY DC

Provider Business Mailing Address
First Line	:	1735 N LA BREA AVE APT 305
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90046-5667
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1735 N LA BREA AVE APT 305
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90046-5667
Country	:	US
Telephone Number	:	401-474-7065
Fax Number	:

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

Provider Enumeration Date	:	03/04/2016
Last Update Date	:	03/04/2016

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