1043596133 NPI number — MRS. VICTORIA LEICHT PA-C

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 1043596133 NPI number — MRS. VICTORIA LEICHT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEICHT
Provider First Name:
VICTORIA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KESSELHON
Provider Other First Name:
VICTORIA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043596133
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6888 GRAND RIVER RD
Provider Second Line Business Mailing Address:
STE 220
Provider Business Mailing Address City Name:
BRIGHTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48114-9345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-220-4422
Provider Business Mailing Address Fax Number:
810-220-1123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
537 STANTON CHRISTIANA RD STE 209
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-2148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-225-0175
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2011

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: 363A00000X , with the licence number:  C5-0000792 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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