MEDICARE: LESLIE GEORGE LMT

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	174400000X	Specialist	515880-06	MI

General Provider Information

NPI Number	:	1255688222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE GEORGE LMT

Provider Business Mailing Address
First Line	:	793 PROMONTORY DR
Second Line	:
City	:	MILFORD
State	:	MI
Zip	:	48381-1656
Country	:	US
Telephone Number	:	248-877-5757
Fax Number	:

Provider Business Practice Location Address
First Line	:	4123 MARTIN RD
Second Line	:	SUITE 201
City	:	COMMERCE TOWNSHIP
State	:	MI
Zip	:	48390-4151
Country	:	US
Telephone Number	:	248-877-5757
Fax Number	:

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

Provider Enumeration Date	:	08/09/2012
Last Update Date	:	08/09/2012

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