Provider Demographics
NPI:1356558795
Name:CORDOVA, LEO JASON RENOVAR (PT)
Entity type:Individual
Prefix:
First Name:LEO JASON
Middle Name:RENOVAR
Last Name:CORDOVA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6216 SANCTUARY POINTE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-9028
Mailing Address - Country:US
Mailing Address - Phone:810-953-0915
Mailing Address - Fax:
Practice Address - Street 1:4466 W BRISTOL RD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3170
Practice Address - Country:US
Practice Address - Phone:810-342-5350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008327225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist