1346594785 NPI number — LESLIE BROOKE LISK DPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346594785 NPI number — LESLIE BROOKE LISK DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LISK
Provider First Name:
LESLIE
Provider Middle Name:
BROOKE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346594785
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1613 WALNUT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27511-5928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-535-8758
Provider Business Mailing Address Fax Number:
919-535-3271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 BLUE RIDGE RD
Provider Second Line Business Practice Location Address:
SUITE 122
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27612-8086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-786-7434
Provider Business Practice Location Address Fax Number:
919-786-7437
Provider Enumeration Date:
11/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  14011 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com