1154432870 NPI number — MICHAEL G LEROUX DC

Table of content: MICHAEL G LEROUX DC (NPI 1154432870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154432870 NPI number — MICHAEL G LEROUX DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEROUX
Provider First Name:
MICHAEL
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154432870
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1920 MINERAL SPRING AVE UNIT 16
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02904-3742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-354-5500
Provider Business Mailing Address Fax Number:
401-354-7470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 SW 80TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34481-1544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-752-9500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC30201 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: DCP00381 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: CH13656 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DC0302010 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 29841 . This is a "BLUE SHIEL D PROVIDER #" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: CH13656 . This is a "STATE OF FL DEPARTMENT OF HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".