Provider Demographics
NPI:1679045546
Name:BASTOS, LEANDRO MODENESE (PT DPT)
Entity Type:Individual
Prefix:
First Name:LEANDRO
Middle Name:MODENESE
Last Name:BASTOS
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 VALE TERRACE DR APT 8
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5228
Mailing Address - Country:US
Mailing Address - Phone:562-212-8477
Mailing Address - Fax:
Practice Address - Street 1:425 DIAMOND DR STE 101
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4495
Practice Address - Country:US
Practice Address - Phone:951-674-9515
Practice Address - Fax:951-674-9517
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296037225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist