Provider Demographics
NPI:1477376556
Name:ROBERTS III, LEON JOSEPH (MINISTRY)
Entity type:Individual
Prefix:
First Name:LEON
Middle Name:JOSEPH
Last Name:ROBERTS III
Suffix:
Gender:M
Credentials:MINISTRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 DAWN CT
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1287
Mailing Address - Country:US
Mailing Address - Phone:925-548-3918
Mailing Address - Fax:
Practice Address - Street 1:3534 E STATE HWY 20 STE 2
Practice Address - Street 2:
Practice Address - City:NICE
Practice Address - State:CA
Practice Address - Zip Code:95464-8573
Practice Address - Country:US
Practice Address - Phone:925-548-3918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner