Provider Demographics
NPI:1912172651
Name:LESLIE CLINIC INC
Entity Type:Organization
Organization Name:LESLIE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PORTER
Authorized Official - Middle Name:BASS
Authorized Official - Last Name:LESLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-922-4283
Mailing Address - Street 1:PO BOX 838
Mailing Address - Street 2:
Mailing Address - City:SEILING
Mailing Address - State:OK
Mailing Address - Zip Code:73663-0838
Mailing Address - Country:US
Mailing Address - Phone:580-922-4283
Mailing Address - Fax:580-922-7717
Practice Address - Street 1:NE HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:SEILING
Practice Address - State:OK
Practice Address - Zip Code:73663-0838
Practice Address - Country:US
Practice Address - Phone:580-922-4283
Practice Address - Fax:580-922-7717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty