Provider Demographics
NPI:1881939445
Name:KIRALLA, LEO SIMON (DPT)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:SIMON
Last Name:KIRALLA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 HILLTOP DR APT 54
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-3797
Mailing Address - Country:US
Mailing Address - Phone:949-378-8213
Mailing Address - Fax:
Practice Address - Street 1:1495 VICTOR AVE
Practice Address - Street 2:SUITE D
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-4093
Practice Address - Country:US
Practice Address - Phone:530-221-9954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39692225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist