Healthcare Provider Details

I. General information

NPI: 1154795615
Provider Name (Legal Business Name): LEAH ANTUNES CMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2015
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MOCKINGBIRD DR
LEXINGTON SC
29073-8739
US

IV. Provider business mailing address

110 MOCKINGBIRD DR
LEXINGTON SC
29073-8739
US

V. Phone/Fax

Practice location:
  • Phone: 803-237-4103
  • Fax:
Mailing address:
  • Phone: 803-237-4103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number47-5267829
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number100295992
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number100295992
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number475267829
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number475267829
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: