1396850897 NPI number — LESLIE A WEATHERHEAD PT

Table of content: LESLIE A WEATHERHEAD PT (NPI 1396850897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396850897 NPI number — LESLIE A WEATHERHEAD PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEATHERHEAD
Provider First Name:
LESLIE
Provider Middle Name:
A
Provider Name Prefix Text:
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:
1396850897
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
236 LE PHILLIP CT., SUITE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28025-1917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-707-4282
Provider Business Mailing Address Fax Number:
704-795-4389

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6604 ROBERTA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARRISBURG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28075-9532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-455-1172
Provider Business Practice Location Address Fax Number:
704-440-0166
Provider Enumeration Date:
08/21/2006

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: 225100000X , with the licence number:  PT22623 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PT22623 . This is a "STATE LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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