1427026764 NPI number — LESLIE WARD DECOU A.R.N.P.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427026764 NPI number — LESLIE WARD DECOU A.R.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DECOU
Provider First Name:
LESLIE
Provider Middle Name:
WARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
A.R.N.P.
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:
1427026764
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 8TH AVE W
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
PALMETTO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34221-4737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-776-4008
Provider Business Mailing Address Fax Number:
941-845-4963

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
37220 GLENWOOD AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYAKKA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-322-6500
Provider Business Practice Location Address Fax Number:
941-322-6505
Provider Enumeration Date:
03/11/2006

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: 363LF0000X , with the licence number:  ARNP1664632 , 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: 001179000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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