Provider Demographics
NPI:1902475510
Name:MEDLEY, LEON EUGENE JR
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:EUGENE
Last Name:MEDLEY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 FELL ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-5144
Mailing Address - Country:US
Mailing Address - Phone:415-861-0828
Mailing Address - Fax:
Practice Address - Street 1:1443 7TH AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-3702
Practice Address - Country:US
Practice Address - Phone:415-861-0828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty