Provider Demographics
NPI:1871223651
Name:RUTHERFORD, LESLIE GILBERT/ GIL
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:GILBERT/ GIL
Last Name:RUTHERFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GIL
Other - Middle Name:
Other - Last Name:RUTHERFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 793
Mailing Address - Street 2:
Mailing Address - City:PAUMA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92061-0793
Mailing Address - Country:US
Mailing Address - Phone:415-250-3730
Mailing Address - Fax:
Practice Address - Street 1:32334 RINCON RANCHO RD
Practice Address - Street 2:
Practice Address - City:PAUMA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92061-9607
Practice Address - Country:US
Practice Address - Phone:415-250-3730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3861225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist