Healthcare Provider Details

I. General information

NPI: 1487063731
Provider Name (Legal Business Name): LEEDS PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1628 9TH ST STE 112
LEEDS AL
35094-4140
US

IV. Provider business mailing address

1628 9TH ST STE 112
LEEDS AL
35094-4140
US

V. Phone/Fax

Practice location:
  • Phone: 205-623-0169
  • Fax: 205-623-0167
Mailing address:
  • Phone: 205-623-0169
  • Fax: 205-623-0167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number302
License Number StateAL

VIII. Authorized Official

Name: DR. LISA ALEXANDRA PANTHEL
Title or Position: OWNER/SOLE MEMBER
Credential: DPM
Phone: 205-623-0169