Provider Demographics
NPI:1871011908
Name:LEE LEONG, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:LEE LEONG
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 1:30116 EIGENBRODT WAY
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-1225
Mailing Address - Country:US
Mailing Address - Phone:510-826-6299
Mailing Address - Fax:
Practice Address - Street 1:30116 EIGENBRODT WAY
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587
Practice Address - Country:US
Practice Address - Phone:510-826-6299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist