Provider Demographics
NPI:1720579147
Name:GEORGE, LEJO
Entity Type:Individual
Prefix:
First Name:LEJO
Middle Name:
Last Name:GEORGE
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 1:701 CORN TASSEL TRL APT 27
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-5442
Mailing Address - Country:US
Mailing Address - Phone:909-809-1046
Mailing Address - Fax:
Practice Address - Street 1:1607 SPRUCE STREET EXT
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-5814
Practice Address - Country:US
Practice Address - Phone:276-632-7146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist