Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 1209 | MS |
Y | 111NN0400X | Neurology | 1209 | MS |
N | 111NN1001X | Nutrition | 1209 | MS |
N | 111NP0017X | Pediatric Chiropractor | 1209 | MS |
N | 111NR0200X | Radiology | 1209 | MS |
N | 213ER0200X | Radiology | 1209 | MS |
N | 111NR0400X | Rehabilitation Chiropractor | 1209 | MS |
N | 111NS0005X | Chiropractic Sports Physician | 1209 | MS |
N | 111NT0100X | Thermography | 1209 | MS |
N | 111NX0100X | Occupational Health | 1209 | MS |
N | 111NX0800X | Chiropractor Orthopedic Specialist | 1209 | MS |
NPI | 1598197584 |
---|---|
Provider Name | Dr. Leslie Kevin Ethridge |
First Address | Newton, MS 39345-2222 |
Second Address | Newton, MS 39345-2222 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2013 |
Last Update Date | 01/08/2013 |