Provider Demographics
NPI:1063008076
Name:LEIVA LAM, ORLY
Entity Type:Individual
Prefix:
First Name:ORLY
Middle Name:
Last Name:LEIVA LAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ORLY
Other - Middle Name:
Other - Last Name:LEIVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1920 GUENTHER RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-9404
Mailing Address - Country:US
Mailing Address - Phone:937-732-6034
Mailing Address - Fax:
Practice Address - Street 1:1920 GUENTHER RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-9404
Practice Address - Country:US
Practice Address - Phone:937-732-6034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5718445376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty