Provider Demographics
NPI:1659126142
Name:TREJO CARDOSO, LEONARDO
Entity Type:Individual
Prefix:
First Name:LEONARDO
Middle Name:
Last Name:TREJO CARDOSO
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 1:248 S 550 W APT C8
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-5552
Mailing Address - Country:US
Mailing Address - Phone:702-626-6677
Mailing Address - Fax:
Practice Address - Street 1:730 S SLEEPY RIDGE DR STE 330
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84059-2613
Practice Address - Country:US
Practice Address - Phone:385-685-6995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13545987-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist