Provider Demographics
NPI:1396856001
Name:WILLIAM E LEADINGHAM, OD, PSC
Entity Type:Organization
Organization Name:WILLIAM E LEADINGHAM, OD, PSC
Other - Org Name:NEURO VISUAL REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEADINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:606-329-8672
Mailing Address - Street 1:PO BOX 2005
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2005
Mailing Address - Country:US
Mailing Address - Phone:606-329-8672
Mailing Address - Fax:606-329-1258
Practice Address - Street 1:1330 CARTER AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7544
Practice Address - Country:US
Practice Address - Phone:606-329-8672
Practice Address - Fax:606-329-1258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY748-DT152W00000X, 152WV0400X
KY1659-DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810007345OtherWEST VIRGINIA MEDICAID
KY77903664Medicaid
KY000000305761OtherANTHEM BLUE CROSS
KY000000305761OtherANTHEM BLUE CROSS
KY77903664Medicaid