1336286343 NPI number — MS. LESLIE KAREN RANDOLPH ANDERSON PT

Table of content: MS. LESLIE KAREN RANDOLPH ANDERSON PT (NPI 1336286343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336286343 NPI number — MS. LESLIE KAREN RANDOLPH ANDERSON PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
LESLIE
Provider Middle Name:
KAREN RANDOLPH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1336286343
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 262
Provider Second Line Business Mailing Address:
11 RAYMOND JOSEPH LANE
Provider Business Mailing Address City Name:
CARIBOU
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04736-2046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-498-1204
Provider Business Mailing Address Fax Number:
207-498-1355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
163 VAN BUREN RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
CARIBOU
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04736-3567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-498-1204
Provider Business Practice Location Address Fax Number:
207-498-1355
Provider Enumeration Date:
01/31/2007

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

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





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