Healthcare Provider Details

I. General information

NPI: 1083610406
Provider Name (Legal Business Name): JEFFREY L LEACH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 S MAIN ST
ORRVILLE OH
44667-2208
US

IV. Provider business mailing address

3001 MAYAPPLE DR
HUDSON OH
44236-2452
US

V. Phone/Fax

Practice location:
  • Phone: 330-682-3010
  • Fax:
Mailing address:
  • Phone: 330-315-8398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberRN-136249
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: