Provider Demographics
NPI:1780029660
Name:BRANCEWICZ, LEONARD JOHN (RPH, NMD)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:JOHN
Last Name:BRANCEWICZ
Suffix:
Gender:M
Credentials:RPH, NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 HIGHWAY 745
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269
Mailing Address - Country:US
Mailing Address - Phone:678-228-8900
Mailing Address - Fax:
Practice Address - Street 1:1200 HIGHWAY 745
Practice Address - Street 2:SUITE 3
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269
Practice Address - Country:US
Practice Address - Phone:678-228-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-06
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP028734L133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist