=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740508282
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALPHA-ZETA BIOMEDICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2010
-----------------------------------------------------
Last Update Date | 05/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2821 GEORGE BUSH HWY SUITE 305
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75082-4266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-394-8437
-----------------------------------------------------
Fax | 972-492-8457
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 PRAIRIE DR
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75007-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-394-8437
-----------------------------------------------------
Fax | 972-492-8457
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | DR. FREDRICK SEBASTIAN LEACH
-----------------------------------------------------
Credential | M.D., PH.D.
-----------------------------------------------------
Telephone | 972-394-8437
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | J9736
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------