MEDICARE: DR. LEON GRANT

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	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	20A16856	CA

General Provider Information

NPI Number	:	1649526203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEON GRANT

Provider Business Mailing Address
First Line	:	10470 OLD PLACERVILLE RD STE 100
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95827-2539
Country	:	US
Telephone Number	:	800-470-0071
Fax Number	:

Provider Business Practice Location Address
First Line	:	1625 STOCKTON BLVD STE 104
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95816-7098
Country	:	US
Telephone Number	:	916-454-6667
Fax Number	:	916-454-6796

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

Provider Enumeration Date	:	07/31/2012
Last Update Date	:	01/24/2019

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