1164617171 NPI number — LEAVENGOOD CHIROPRACTIC, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164617171 NPI number — LEAVENGOOD CHIROPRACTIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEAVENGOOD CHIROPRACTIC, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1164617171
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1238 S HOUSTON LAKE RD
Provider Second Line Business Mailing Address:
STE 3
Provider Business Mailing Address City Name:
WARNER ROBINS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31088-0723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-988-4663
Provider Business Mailing Address Fax Number:
478-988-4881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1238 S HOUSTON LAKE RD
Provider Second Line Business Practice Location Address:
STE 3
Provider Business Practice Location Address City Name:
WARNER ROBINS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31088-0723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-988-4663
Provider Business Practice Location Address Fax Number:
478-988-4881
Provider Enumeration Date:
09/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEAVENGOOD
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
LINDELIE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
478-988-4663

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2823 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00490421A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1346304078 . This is a "INDIVIUAL NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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