Provider Demographics
NPI:1255927059
Name:LEASE, THEODORE
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:LEASE
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 1:85 ROCKLAND FARM DR
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-8894
Mailing Address - Country:US
Mailing Address - Phone:304-209-2542
Mailing Address - Fax:
Practice Address - Street 1:106 DOLLS GAP RD
Practice Address - Street 2:
Practice Address - City:NEW CREEK
Practice Address - State:WV
Practice Address - Zip Code:26743-7101
Practice Address - Country:US
Practice Address - Phone:304-790-4602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant