Healthcare Provider Details

I. General information

NPI: 1164747531
Provider Name (Legal Business Name): ANGELA DAWN LEACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 03/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3826 MARION ST
CORPUS CHRISTI TX
78415-2531
US

IV. Provider business mailing address

3826 MARION ST
CORPUS CHRISTI TX
78415-2531
US

V. Phone/Fax

Practice location:
  • Phone: 361-944-2276
  • Fax:
Mailing address:
  • Phone: 361-944-2276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateTX

VIII. Authorized Official

Name: MS. ANGELA DAWN LEACH
Title or Position: OWNER/MANAGER
Credential:
Phone: 361-944-2276