Healthcare Provider Details

I. General information

NPI: 1306191218
Provider Name (Legal Business Name): BEN LEONARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 INDUSTRIAL PKWY
CALVERT CITY KY
42029-8416
US

IV. Provider business mailing address

43 INDUSTRIAL PKWY
CALVERT CITY KY
42029-8416
US

V. Phone/Fax

Practice location:
  • Phone: 270-395-8331
  • Fax:
Mailing address:
  • Phone: 270-395-8331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1896DT
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number1896DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: