Provider Demographics
NPI:1609976810
Name:HUDDLESTON, LEO C
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:C
Last Name:HUDDLESTON
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 1:6500 OLD CANTON RD
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1313
Mailing Address - Country:US
Mailing Address - Phone:601-956-0010
Mailing Address - Fax:601-956-7953
Practice Address - Street 1:6500 OLD CANTON RD
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1313
Practice Address - Country:US
Practice Address - Phone:601-956-0010
Practice Address - Fax:601-956-7953
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS624111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS350000184Medicare PIN