Provider Demographics
NPI:1376712448
Name:LEITHERLAND FAMILY CARE CLINIC, PLLC
Entity Type:Organization
Organization Name:LEITHERLAND FAMILY CARE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEITHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:FNPC
Authorized Official - Phone:731-692-2853
Mailing Address - Street 1:1123 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:TN
Mailing Address - Zip Code:38330-1019
Mailing Address - Country:US
Mailing Address - Phone:731-692-2853
Mailing Address - Fax:731-692-2367
Practice Address - Street 1:1123 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:TN
Practice Address - Zip Code:38330-1019
Practice Address - Country:US
Practice Address - Phone:731-692-2853
Practice Address - Fax:731-692-2367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN5603261QP2300X
TNRN53289261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNS66580OtherUPIN