Provider Demographics
NPI:1801064803
Name:DR. LEON GRESHAM
Entity type:Organization
Organization Name:DR. LEON GRESHAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:
Authorized Official - Last Name:GRESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:706-629-8266
Mailing Address - Street 1:100 S COURT ST
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-2296
Mailing Address - Country:US
Mailing Address - Phone:706-629-8266
Mailing Address - Fax:706-629-8267
Practice Address - Street 1:100 S COURT ST
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-2296
Practice Address - Country:US
Practice Address - Phone:706-629-8266
Practice Address - Fax:706-629-8267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00005233AMedicaid
GA00005233AMedicaid
GA0620860001Medicare NSC