Healthcare Provider Details

I. General information

NPI: 1639708571
Provider Name (Legal Business Name): REBECCA BRADLEIGH LELAND CO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 HARDEN STREET EXT STE 200
COLUMBIA SC
29203-6842
US

IV. Provider business mailing address

2534 EMPIRE DR
WINSTON SALEM NC
27103-6710
US

V. Phone/Fax

Practice location:
  • Phone: 803-939-0097
  • Fax: 803-939-1103
Mailing address:
  • Phone: 336-397-0993
  • Fax: 336-397-2167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCO006167
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: