Healthcare Provider Details

I. General information

NPI: 1417211301
Provider Name (Legal Business Name): BRIAN LECLEIR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE MC #13
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

2590 KNIGHTSBRIDGE RD SE
GRAND RAPIDS MI
49546-6755
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-0073
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301101263
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: