Provider Demographics
NPI:1013981760
Name:SPORTS & ORTHOPEDIC LEADERS PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:SPORTS & ORTHOPEDIC LEADERS PHYSICAL THERAPY, INC
Other - Org Name:SPORTS AND ORTHOPEDIC LEADERS, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:616-356-5000
Mailing Address - Street 1:4341 PIEDMONT AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-4792
Mailing Address - Country:US
Mailing Address - Phone:616-356-5000
Mailing Address - Fax:616-356-5001
Practice Address - Street 1:4341 PIEDMONT AVE STE 201
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611
Practice Address - Country:US
Practice Address - Phone:510-547-1630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-16
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CAPT15427225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ23789ZMedicare PIN