Provider Demographics
NPI:1114144169
Name:LEACH, ROLLAND DEAN (LMBT)
Entity Type:Individual
Prefix:MR
First Name:ROLLAND
Middle Name:DEAN
Last Name:LEACH
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 DANIEL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-6817
Mailing Address - Country:US
Mailing Address - Phone:910-455-7225
Mailing Address - Fax:
Practice Address - Street 1:1012 DANIEL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-6817
Practice Address - Country:US
Practice Address - Phone:910-455-7225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1584225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist