Provider Demographics
NPI:1730493131
Name:LEATHERWOOD, CHARLES
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:LEATHERWOOD
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 1:3910 NEYLAND VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135-4215
Mailing Address - Country:US
Mailing Address - Phone:901-382-0208
Mailing Address - Fax:
Practice Address - Street 1:3910 NEYLAND VALLEY DR
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38135-4215
Practice Address - Country:US
Practice Address - Phone:901-382-0208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator