Healthcare Provider Details

I. General information

NPI: 1861858987
Provider Name (Legal Business Name): LESLIE S COLEY CERTIFIED HAIR LOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1484 GULF TO BAY BLVD UNIT 4
CLEARWATER FL
33755
US

IV. Provider business mailing address

1484 GULF TO BAY BLVD UNIT 4
CLEARWATER FL
33755
US

V. Phone/Fax

Practice location:
  • Phone: 813-530-6773
  • Fax:
Mailing address:
  • Phone: 813-530-6773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCL1181442
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: