Provider Demographics
NPI:1447470505
Name:LEONORA, ROLAND MARTINUS (PT)
Entity type:Individual
Prefix:
First Name:ROLAND
Middle Name:MARTINUS
Last Name:LEONORA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 MARQUETTE ST.
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706
Mailing Address - Country:US
Mailing Address - Phone:989-402-1215
Mailing Address - Fax:989-402-1218
Practice Address - Street 1:1607 MARQUETTE ST.
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706
Practice Address - Country:US
Practice Address - Phone:989-402-1215
Practice Address - Fax:989-402-1218
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP45540009Medicare PIN
MIP45530009Medicare PIN