Healthcare Provider Details

I. General information

NPI: 1073784351
Provider Name (Legal Business Name): DONALD B. LEACH, O.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

943 MAIN STREET SW
LOS LUNAS NM
87031-8748
US

IV. Provider business mailing address

943 MAIN STREET SW
LOS LUNAS NM
87031-8748
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-4812
  • Fax: 505-865-3767
Mailing address:
  • Phone: 505-865-4812
  • Fax: 505-865-3767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number245/OP2245
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number245/OP2245
License Number StateNM

VIII. Authorized Official

Name: DR. DONALD B LEACH
Title or Position: PRESIDENT/DOCTOR
Credential: O.D.
Phone: 505-865-4812