Provider Demographics
NPI:1689903908
Name:LEALOS, SADIE ANNA (LMT)
Entity Type:Individual
Prefix:MISS
First Name:SADIE
Middle Name:ANNA
Last Name:LEALOS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3222 28TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-5183
Mailing Address - Country:US
Mailing Address - Phone:701-232-4770
Mailing Address - Fax:701-237-3251
Practice Address - Street 1:3222 28TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-5183
Practice Address - Country:US
Practice Address - Phone:701-232-4770
Practice Address - Fax:701-237-3251
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND723172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist