Provider Demographics
NPI:1093784407
Name:LEONARD, BO C (ATC, MS)
Entity Type:Individual
Prefix:MR
First Name:BO
Middle Name:C
Last Name:LEONARD
Suffix:
Gender:M
Credentials:ATC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-3436
Mailing Address - Country:US
Mailing Address - Phone:708-283-9765
Mailing Address - Fax:
Practice Address - Street 1:906 S STATE ST
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-3436
Practice Address - Country:US
Practice Address - Phone:708-283-9765
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer