1558566521 NPI number — CLIFFORD MATTHEW LEACH 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 1558566521 NPI number — CLIFFORD MATTHEW LEACH DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEACH
Provider First Name:
CLIFFORD
Provider Middle Name:
MATTHEW
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEACH
Provider Other First Name:
MATT
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1558566521
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6045 ALMA RD
Provider Second Line Business Mailing Address:
STE 320
Provider Business Mailing Address City Name:
MCKINNEY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75070-2188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-569-9050
Provider Business Mailing Address Fax Number:
972-569-9076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6045 ALMA DR
Provider Second Line Business Practice Location Address:
STE 320
Provider Business Practice Location Address City Name:
MCKINNEY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-569-9050
Provider Business Practice Location Address Fax Number:
972-569-9076
Provider Enumeration Date:
06/19/2007

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:  1172280 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 207749701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 824T43 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8T7285 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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