=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104014687
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMES C LEADINGHAM, O.D., PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2007
-----------------------------------------------------
Last Update Date | 08/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 VINSON BLVD
-----------------------------------------------------
City | LOUISA
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41230-1155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-638-4731
-----------------------------------------------------
Fax | 606-638-3523
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 VINSON BLVD
-----------------------------------------------------
City | LOUISA
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-638-4731
-----------------------------------------------------
Fax | 606-638-3523
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR/OWNER
-----------------------------------------------------
Name | DR. JAMES C LEADINGHAM
-----------------------------------------------------
Credential | O.D. PSC
-----------------------------------------------------
Telephone | 606-638-4731
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0731DT
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------