Basic Information
| Provider Information | |||||||||
| NPI: | 1326229485 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DPMLEONHEARTPRWA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11201 88TH AVE E | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983733802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538413668 | ||||||||
| FaxNumber: | 2538410878 | ||||||||
| Practice Location | |||||||||
| Address1: | 10116 116TH ST E | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983733543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538413668 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2007 | ||||||||
| LastUpdateDate: | 10/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEONHEART | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2538413668 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | PO00000778 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1121714 | 05 | WA | MEDICAID |