Provider Demographics
NPI:1396095642
Name:PECK, GREGORY LEO (LPTA)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:LEO
Last Name:PECK
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9017 BUCKEYE DR
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6007
Mailing Address - Country:US
Mailing Address - Phone:951-203-9017
Mailing Address - Fax:
Practice Address - Street 1:9017 BUCKEYE DR
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6007
Practice Address - Country:US
Practice Address - Phone:951-203-9017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2266172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist