Provider Demographics
NPI:1790141364
Name:LEIGH, CLYDE II (MT)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:LEIGH
Suffix:II
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 ELMRIDGE DR NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-2306
Mailing Address - Country:US
Mailing Address - Phone:616-648-7707
Mailing Address - Fax:
Practice Address - Street 1:890 3 MILE RD NW STE 1
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8216
Practice Address - Country:US
Practice Address - Phone:616-460-9814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501003119225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist