Provider Demographics
NPI:1598197584
Name:ETHRIDGE, LESLIE KEVIN (DC)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:KEVIN
Last Name:ETHRIDGE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 FORD AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MS
Mailing Address - Zip Code:39345-2222
Mailing Address - Country:US
Mailing Address - Phone:601-527-9707
Mailing Address - Fax:
Practice Address - Street 1:124 FORD AVE
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MS
Practice Address - Zip Code:39345-2222
Practice Address - Country:US
Practice Address - Phone:601-527-9707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1209111N00000X, 111NN0400X, 111NN1001X, 111NP0017X, 111NR0200X, 111NR0400X, 111NS0005X, 111NT0100X, 111NX0100X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
No111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition
No111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor
No111NR0200XChiropractic ProvidersChiropractorRadiology
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NT0100XChiropractic ProvidersChiropractorThermography
No111NX0100XChiropractic ProvidersChiropractorOccupational Health
No111NX0800XChiropractic ProvidersChiropractorOrthopedic