Provider Demographics
NPI:1154579514
Name:LESLIE N RICHARDSON, O.D. PSC
Entity type:Organization
Organization Name:LESLIE N RICHARDSON, O.D. PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-465-3669
Mailing Address - Street 1:725 CAMPBELLSVILLE BYP
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-8846
Mailing Address - Country:US
Mailing Address - Phone:270-465-3669
Mailing Address - Fax:270-465-3579
Practice Address - Street 1:725 CAMPBELLSVILLE BYP
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-8846
Practice Address - Country:US
Practice Address - Phone:270-465-3669
Practice Address - Fax:270-465-3579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-28
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0851DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0242Medicare PIN