Provider Demographics
NPI:1639123771
Name:JOHN LECLAIRE M.D., P.L.C.
Entity Type:Organization
Organization Name:JOHN LECLAIRE M.D., P.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LECLAIRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-728-3749
Mailing Address - Street 1:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-0086
Mailing Address - Country:US
Mailing Address - Phone:231-780-6086
Mailing Address - Fax:231-780-6093
Practice Address - Street 1:172 E FOREST AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5541
Practice Address - Country:US
Practice Address - Phone:231-728-3749
Practice Address - Fax:231-722-4652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJL038974174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1375648Medicaid
MI0610024Medicare ID - Type Unspecified
MI1375648Medicaid