1245325810 NPI number — MR. MICHAEL FREDRICK LEBLANC RPH

Table of content: MR. MICHAEL FREDRICK LEBLANC RPH (NPI 1245325810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245325810 NPI number — MR. MICHAEL FREDRICK LEBLANC RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEBLANC
Provider First Name:
MICHAEL
Provider Middle Name:
FREDRICK
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPH
Provider Gender Code:
M

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:
1245325810
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 CALLEY COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST JOHNS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-287-8596
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5050 EDGEWOOD CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-783-5897
Provider Business Practice Location Address Fax Number:
904-783-5089
Provider Enumeration Date:
10/03/2006

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: 183500000X , with the licence number:  14402 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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