Provider Demographics
NPI:1043644149
Name:HALL, LEONARD BUCKRIDGE (PT)
Entity Type:Individual
Prefix:MR
First Name:LEONARD
Middle Name:BUCKRIDGE
Last Name:HALL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4434 MATICH DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-6375
Mailing Address - Country:US
Mailing Address - Phone:775-772-7466
Mailing Address - Fax:
Practice Address - Street 1:CALIFORNIA MENS COLONY HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93409-0001
Practice Address - Country:US
Practice Address - Phone:805-547-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20618171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor