Provider Demographics
NPI:1194070961
Name:LECLAIR, DOUGLAS (CO)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:LECLAIR
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24905
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-4905
Mailing Address - Country:US
Mailing Address - Phone:336-397-2165
Mailing Address - Fax:336-397-2167
Practice Address - Street 1:1677 WESTBROOK PLAZA DR
Practice Address - Street 2:SUITE 190
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3065
Practice Address - Country:US
Practice Address - Phone:336-765-2425
Practice Address - Fax:336-765-8370
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist