1184768491 NPI number — DR. TINA MARIE LEISURE

Table of content: DR. TINA MARIE LEISURE (NPI 1184768491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184768491 NPI number — DR. TINA MARIE LEISURE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEISURE
Provider First Name:
TINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1184768491
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
839 LARKMEAD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARKERSBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26101-7579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-481-4526
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 WESTERN HILLS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARKERSBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26105-8122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-420-1395
Provider Business Practice Location Address Fax Number:
304-420-1364
Provider Enumeration Date:
02/19/2007

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: 103T00000X , with the licence number:  684 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3810007824 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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