Provider Demographics
NPI:1154413797
Name:LIDDICOAT, LEANNE M (OD)
Entity type:Individual
Prefix:
First Name:LEANNE
Middle Name:M
Last Name:LIDDICOAT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 N SUNRISE AVE
Mailing Address - Street 2:SUITE C2
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2916
Mailing Address - Country:US
Mailing Address - Phone:916-786-2212
Mailing Address - Fax:916-786-2393
Practice Address - Street 1:114 N SUNRISE AVE
Practice Address - Street 2:SUITE C2
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2916
Practice Address - Country:US
Practice Address - Phone:916-786-2212
Practice Address - Fax:916-786-2393
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11076T152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU76797Medicare UPIN
CASD0011760Medicare ID - Type Unspecified