Provider Demographics
NPI:1770302788
Name:SANSON, LEAH (LDO)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:SANSON
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 CHURCH ST STE A
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-4440
Mailing Address - Country:US
Mailing Address - Phone:843-365-0739
Mailing Address - Fax:843-365-0751
Practice Address - Street 1:2709 CHURCH ST STE A
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4440
Practice Address - Country:US
Practice Address - Phone:843-365-0739
Practice Address - Fax:843-365-0751
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1458156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician