1679103691 NPI number — MR. LEECHANN MCMANUS EXECUTIVE DIRECTOR

Table of content: MR. LEECHANN MCMANUS EXECUTIVE DIRECTOR (NPI 1679103691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679103691 NPI number — MR. LEECHANN MCMANUS EXECUTIVE DIRECTOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCMANUS
Provider First Name:
LEECHANN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
EXECUTIVE DIRECTOR
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TABORN
Provider Other First Name:
KEDIAN
Provider Other Middle Name:
DARIUS
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CFO
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1679103691
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
440 CHARLES ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28677-6806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-257-1086
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
440 CHARLES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28677-6806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-257-1086
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/17/2020

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: 101YM0800X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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