Healthcare Provider Details

I. General information

NPI: 1396856001
Provider Name (Legal Business Name): WILLIAM E LEADINGHAM, OD, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 CARTER AVE
ASHLAND KY
41101-7544
US

IV. Provider business mailing address

PO BOX 2005
ASHLAND KY
41105-2005
US

V. Phone/Fax

Practice location:
  • Phone: 606-329-8672
  • 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 Code152W00000X
TaxonomyOptometrist
License Number1659-DT
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number748-DT
License Number StateKY

VIII. Authorized Official

Name: DR. WILLIAM E LEADINGHAM
Title or Position: OWNER
Credential: OD
Phone: 606-329-8672