Healthcare Provider Details

I. General information

NPI: 1437792777
Provider Name (Legal Business Name): VIRGINIA E LEACH AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIRGINIA E LAND AUD

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 MID CITIES BLVD STE 110
HURST TX
76054-2793
US

IV. Provider business mailing address

PO BOX 99213
FORT WORTH TX
76199-0213
US

V. Phone/Fax

Practice location:
  • Phone: 817-347-2955
  • Fax: 817-656-3659
Mailing address:
  • Phone: 682-885-1860
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number81206
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: