Basic Information
| Provider Information | |||||||||
| NPI: | 1902918030 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEAHY FAMILY CARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 S CABLE RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458053467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192241234 | ||||||||
| FaxNumber: | 4192246800 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 S CABLE RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458053467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192241234 | ||||||||
| FaxNumber: | 4192246800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LEAHY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4192241234 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 2156518 | 05 | OH | MEDICAID |