1104992189 NPI number — REBECCA A LESLIE RD

Table of content: REBECCA A LESLIE RD (NPI 1104992189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104992189 NPI number — REBECCA A LESLIE RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LESLIE
Provider First Name:
REBECCA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD
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:
1104992189
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15606 258TH PL SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ISSAQUAH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98027-8257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-205-1940
Provider Business Mailing Address Fax Number:
206-205-5499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1404 CENTRAL AVE S
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
KENT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98032-7433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-205-1940
Provider Business Practice Location Address Fax Number:
206-205-5499
Provider Enumeration Date:
11/28/2006

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: 133V00000X , with the licence number:  DI00000657 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8270118 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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