Basic Information
Provider Information | |||||||||
NPI: | 1376568907 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEO | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | G | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LLC | ||||||||
OtherFirstName: | RGL | ||||||||
OtherMiddleName: | MEDICAL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1561 W 7000 S | ||||||||
Address2: | SUITE 102 | ||||||||
City: | WEST JORDAN | ||||||||
State: | UT | ||||||||
PostalCode: | 840843556 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015689895 | ||||||||
FaxNumber: | 8013520400 | ||||||||
Practice Location | |||||||||
Address1: | 1561 W 7000 S | ||||||||
Address2: | SUITE 102 | ||||||||
City: | WEST JORDAN | ||||||||
State: | UT | ||||||||
PostalCode: | 840843556 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015689895 | ||||||||
FaxNumber: | 8013520400 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2006 | ||||||||
LastUpdateDate: | 11/19/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247100000X | 116092-5401 | UT | Y |   | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist |   |
ID Information
ID | Type | State | Issuer | Description | 841375719001 | 05 | UT |   | MEDICAID |