1538349030 NPI number — LESLIE CANYON FAMILY MEDICINE, P.S.

Table of content: (NPI 1538349030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538349030 NPI number — LESLIE CANYON FAMILY MEDICINE, P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LESLIE CANYON FAMILY MEDICINE, P.S.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1538349030
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
705 GAGE BLVD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
RICHLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99352-9701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-628-2331
Provider Business Mailing Address Fax Number:
509-628-0537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 GAGE BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
RICHLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99352-9701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-628-2331
Provider Business Practice Location Address Fax Number:
509-628-0537
Provider Enumeration Date:
11/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MEGNA
Authorized Official First Name:
LUCIEN
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PRESIDIENT / CEO
Authorized Official Telephone Number:
509-628-2331

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  WA00034155 , 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: 7077993 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11151316 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".




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