Provider Demographics
NPI:1447490453
Name:LESLIE CLINIC INC.
Entity type:Organization
Organization Name:LESLIE CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR/PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PORTER
Authorized Official - Middle Name:BASS
Authorized Official - Last Name:LESLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-995-3200
Mailing Address - Street 1:PO BOX 45
Mailing Address - Street 2:
Mailing Address - City:VICI
Mailing Address - State:OK
Mailing Address - Zip Code:73859-0045
Mailing Address - Country:US
Mailing Address - Phone:580-995-3200
Mailing Address - Fax:580-995-3202
Practice Address - Street 1:RR 1 BOX A1
Practice Address - Street 2:
Practice Address - City:VICI
Practice Address - State:OK
Practice Address - Zip Code:73859-9106
Practice Address - Country:US
Practice Address - Phone:580-995-3200
Practice Address - Fax:580-995-3202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10616261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK315465837Medicare PIN