Healthcare Provider Details

I. General information

NPI: 1386614782
Provider Name (Legal Business Name): SUZANNE LEAH LEACH, OD O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUZANNE LEAH LEACH, OD O.D.

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 01/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 STATE ROUTE 127 N SUITE A
EATON OH
45320-9284
US

IV. Provider business mailing address

1845 STATE ROUTE 127 N SUITE A
EATON OH
45320-9284
US

V. Phone/Fax

Practice location:
  • Phone: 937-472-5665
  • Fax: 937-472-3933
Mailing address:
  • Phone: 937-472-5665
  • Fax: 937-472-3933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4119/T938
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: