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General NPI Number Information
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NPI Number | 1689094039
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Entity Type | Organization
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Legal Business Name | NORTHEAST KINGDOM HEMATOLOGY ONCOLOGY PLLC
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Dates
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Enumeration Date | 04/24/2014
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Last Update Date | 10/28/2014
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Provider Practice Location Address
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Address Line | 637 UNION ST
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City | NEWPORT
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State | VT
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Zip | 05855-5498
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Country | US
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Telephone | 802-334-7177
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Fax | 802-487-9299
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Provider Business Mailing Address
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Address Line | PO BOX 838 637 UNION STREET
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City | NEWPORT
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State | VT
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Zip | 05855-5498
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Country | US
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Telephone | 802-334-7177
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Fax | 802-487-9299
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Authorized Official
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Title or Position | SOLE PROPRIETOR/SOLE OWNER
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Name | DR. LESLIE C LOCKRIDGE
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Credential | MD
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Telephone | 802-334-7177
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number | 0420011226
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License Number State | VT
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