Provider Demographics
NPI:1093259491
Name:LESLIE RICHARDSON, LLC
Entity Type:Organization
Organization Name:LESLIE RICHARDSON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-470-7130
Mailing Address - Street 1:2820 JANE LN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-2746
Mailing Address - Country:US
Mailing Address - Phone:402-470-7130
Mailing Address - Fax:
Practice Address - Street 1:3201 PIONEERS BLVD
Practice Address - Street 2:112
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-5963
Practice Address - Country:US
Practice Address - Phone:402-486-3110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE147251S00000X
NE3827251S00000X
NE1136251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE98402OtherBCBS