1538195094 NPI number — JEFFEY O LEACH, M.D. INC

Table of content: (NPI 1538195094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538195094 NPI number — JEFFEY O LEACH, M.D. INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFEY O LEACH, M.D. INC
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:
1538195094
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2067 W VISTA WAY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
VISTA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92083-6031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-941-9844
Provider Business Mailing Address Fax Number:
960-630-5716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2067 W VISTA WAY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92083-6031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-941-9844
Provider Business Practice Location Address Fax Number:
760-630-5716
Provider Enumeration Date:
06/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERSON
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICARE BILLING SPECIALIST
Authorized Official Telephone Number:
760-941-9844

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G30939 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: OOG309390 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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