Healthcare Provider Details

I. General information

NPI: 1073505814
Provider Name (Legal Business Name): WILLIAM E LEADINGHAM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: NEURO VISUAL REHABILITATION CENTER OD

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 12/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 CARTER AVE STE 3
ASHLAND KY
41101-7544
US

IV. Provider business mailing address

PO BOX 2005 STE 3
ASHLAND KY
41105-2005
US

V. Phone/Fax

Practice location:
  • Phone: 606-329-1258
  • Fax: 606-329-1258
Mailing address:
  • Phone: 606-329-8672
  • Fax: 606-329-1258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number748-DT
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number748-DT
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number748-DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: