Basic Information
| Provider Information | |||||||||
| NPI: | 1992814404 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEACH | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2865 CHANCELLOR DR | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593442079 | ||||||||
| FaxNumber: | 8595817207 | ||||||||
| Practice Location | |||||||||
| Address1: | 1577 GOODMAN AVE STE B | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452241044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137291321 | ||||||||
| FaxNumber: | 5137292873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4416 | OH | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0095608 | 05 | OH | MEDICAID |