Provider Demographics
NPI:1255543443
Name:NABOURS, LESLIE (LESLIE NABOURS,ABOC)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:NABOURS
Suffix:
Gender:F
Credentials:LESLIE NABOURS,ABOC
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:NABOURS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LESLIE NABOURS,ABOC
Mailing Address - Street 1:400 W. SPRUCE ST.
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-8803
Mailing Address - Country:US
Mailing Address - Phone:505-546-9757
Mailing Address - Fax:505-546-3006
Practice Address - Street 1:400 W. SPRUCE ST.
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-8803
Practice Address - Country:US
Practice Address - Phone:505-546-9757
Practice Address - Fax:505-546-3006
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM156FX1800XMedicaid