Basic Information
| Provider Information | |||||||||
| NPI: | 1679700371 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEBLANC | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | MONTGOMERY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3905 NEW BERN AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192316040 | ||||||||
| FaxNumber: | 9192316044 | ||||||||
| Practice Location | |||||||||
| Address1: | 3905 NEW BERN AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192316040 | ||||||||
| FaxNumber: | 9192316044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2009 | ||||||||
| LastUpdateDate: | 08/29/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618001852 | VA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2159 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | AO5134 | 01 | NC | EYEMED | OTHER | 5914851 | 05 | NC | MEDICAID | 0932M | 01 | NC | BCBS PROV # | OTHER |