1326100298 NPI number — DR. LESLIE ALLYSON HACKWORTH O.D.

Table of content: DR. LESLIE ALLYSON HACKWORTH O.D. (NPI 1326100298)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326100298 NPI number — DR. LESLIE ALLYSON HACKWORTH O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HACKWORTH
Provider First Name:
LESLIE
Provider Middle Name:
ALLYSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1326100298
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HC01 BOX 8150
Provider Second Line Business Mailing Address:
SAN SIMON INDIAN HEALTH CENTER
Provider Business Mailing Address City Name:
SELLS
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85634-9737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-235-0344
Provider Business Mailing Address Fax Number:
520-363-7080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HWY 86, MILE MARKER 74
Provider Second Line Business Practice Location Address:
EYE CLINIC, SAN SIMON INDIAN HEALTH CENTER
Provider Business Practice Location Address City Name:
N/A
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85634-9716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-235-0344
Provider Business Practice Location Address Fax Number:
520-362-7080
Provider Enumeration Date:
12/15/2006

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: 152W00000X , with the licence number:  002586 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004237097 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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