Healthcare Provider Details

I. General information

NPI: 1912172651
Provider Name (Legal Business Name): LESLIE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NE HIGHWAY 60
SEILING OK
73663-0838
US

IV. Provider business mailing address

PO BOX 838
SEILING OK
73663-0838
US

V. Phone/Fax

Practice location:
  • Phone: 580-922-4283
  • Fax: 580-922-7717
Mailing address:
  • Phone: 580-922-4283
  • Fax: 580-922-7717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PORTER BASS LESLIE
Title or Position: OWNER
Credential: M.D.
Phone: 580-922-4283