Provider Demographics
NPI:1285453811
Name:LEO CLINIC INC
Entity type:Organization
Organization Name:LEO CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:MARRERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-249-0975
Mailing Address - Street 1:602 NEW BRITAIN AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-4033
Mailing Address - Country:US
Mailing Address - Phone:860-249-0975
Mailing Address - Fax:
Practice Address - Street 1:602 NEW BRITAIN AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-4033
Practice Address - Country:US
Practice Address - Phone:860-249-0975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care