Provider Demographics
NPI:1164568291
Name:LEROY, LIONEL (SAC)
Entity Type:Individual
Prefix:
First Name:LIONEL
Middle Name:
Last Name:LEROY
Suffix:
Gender:M
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10111 W FOREST HILL BLVD RM 231
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6157
Mailing Address - Country:US
Mailing Address - Phone:561-784-7014
Mailing Address - Fax:561-784-7922
Practice Address - Street 1:10111 W FOREST HILL BLVD RM 231
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6157
Practice Address - Country:US
Practice Address - Phone:561-784-7014
Practice Address - Fax:561-784-7922
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL06-260246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist