Provider Demographics
NPI:1568953115
Name:LEECH, RAYMOND D
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:D
Last Name:LEECH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 22ND ST S
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39701-6606
Mailing Address - Country:US
Mailing Address - Phone:662-574-1265
Mailing Address - Fax:662-630-5077
Practice Address - Street 1:618 22ND ST S
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39701-6606
Practice Address - Country:US
Practice Address - Phone:662-574-1265
Practice Address - Fax:662-630-5077
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor