Provider Demographics
NPI:1568074284
Name:GALVEZ LEIVA, SERGIO FRANCISCO (LMT)
Entity Type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:FRANCISCO
Last Name:GALVEZ LEIVA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 SW 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-7222
Mailing Address - Country:US
Mailing Address - Phone:954-850-6854
Mailing Address - Fax:
Practice Address - Street 1:311 SE 15 AVENUE
Practice Address - Street 2:5
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL50725225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist