Provider Demographics
NPI:1487202867
Name:DELATORRE, LEOPOLDO MIRANDA (LMT)
Entity Type:Individual
Prefix:
First Name:LEOPOLDO
Middle Name:MIRANDA
Last Name:DELATORRE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:LEO
Other - Middle Name:
Other - Last Name:DE LA TORRE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1702 E 5600 S
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4384
Mailing Address - Country:US
Mailing Address - Phone:801-689-2546
Mailing Address - Fax:
Practice Address - Street 1:5261 ADAMS AVE PKWY
Practice Address - Street 2:
Practice Address - City:WASHINGTON TERRACE
Practice Address - State:UT
Practice Address - Zip Code:84405-6748
Practice Address - Country:US
Practice Address - Phone:801-475-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9730693-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist