Basic Information
| Provider Information | |||||||||
| NPI: | 1720086549 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIECO | ||||||||
| FirstName: | LEONARD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 STATE ST | ||||||||
| Address2: | SUITE 16,LL | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165011341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144807100 | ||||||||
| FaxNumber: | 8144807604 | ||||||||
| Practice Location | |||||||||
| Address1: | TRAC REHAB PEACH | ||||||||
| Address2: | 5100 PEACH STREET | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148645097 | ||||||||
| FaxNumber: | 8148649583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT000355E | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0016785750006 | 05 | PA | MEDICAID | 3110682 | 01 | PA | AETNA | OTHER | 00025600602 | 01 | NY | UNIVERA | OTHER | 669114 | 01 | PA | BLUE SHIELD | OTHER | P00111335 | 01 | PA | RR MEDICARE | OTHER |