Healthcare Provider Details

I. General information

NPI: 1962802025
Provider Name (Legal Business Name): LEANNA CHARLESTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 S GULLEY RD STE F-G
DEARBORN MI
48124-4406
US

IV. Provider business mailing address

136 WILLIAM ST
SPRINGFIELD MA
01105-2324
US

V. Phone/Fax

Practice location:
  • Phone: 734-407-2500
  • Fax:
Mailing address:
  • Phone: 800-218-9280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: