Provider Demographics
NPI:1699492603
Name:IDEHEN, LERIS
Entity type:Individual
Prefix:
First Name:LERIS
Middle Name:
Last Name:IDEHEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 CAT TAIL WAY
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-2559
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4302 CAT TAIL WAY
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-2559
Practice Address - Country:US
Practice Address - Phone:214-283-6759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine