Healthcare Provider Details

I. General information

NPI: 1407366362
Provider Name (Legal Business Name): MARSHA LEAKE VICE PRESIDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5724 STAGE RD STE F
BARTLETT TN
38134-4572
US

IV. Provider business mailing address

4630 ORANGE TULIP DR
MEMPHIS TN
38135-0749
US

V. Phone/Fax

Practice location:
  • Phone: 901-383-0417
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: