Provider Demographics
NPI:1588750194
Name:KLIETHERMES, LESLIE (OD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:KLIETHERMES
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 1:176 HEIDI DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:RI
Mailing Address - Zip Code:02871-3517
Mailing Address - Country:US
Mailing Address - Phone:254-423-0536
Mailing Address - Fax:
Practice Address - Street 1:70 PROVIDENCE PL
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-1747
Practice Address - Country:US
Practice Address - Phone:401-243-0685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX05575T152W00000X
RIODTA00547152W00000X
HIOD681152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist