Provider Demographics
NPI:1568060788
Name:LEACOCK, ENOCH
Entity Type:Individual
Prefix:MR
First Name:ENOCH
Middle Name:
Last Name:LEACOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 SALT POND PL UNIT 102
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7635
Mailing Address - Country:US
Mailing Address - Phone:407-923-0458
Mailing Address - Fax:
Practice Address - Street 1:6900 S ORANGE BLOSSOM TRL STE 304
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-5736
Practice Address - Country:US
Practice Address - Phone:407-923-0458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA90560225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist