Provider Demographics
NPI:1588268569
Name:LEONARD, LESLIE L IV (CEO)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:L
Last Name:LEONARD
Suffix:IV
Gender:M
Credentials:CEO
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 140271
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-0271
Mailing Address - Country:US
Mailing Address - Phone:419-308-4609
Mailing Address - Fax:
Practice Address - Street 1:5881 STAGHORN DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-4564
Practice Address - Country:US
Practice Address - Phone:419-308-4609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
4810133376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0295969Medicaid