1326582008 NPI number — DOCTORLEO LLC

Table of content: (NPI 1326582008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326582008 NPI number — DOCTORLEO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOCTORLEO LLC
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:
THECHIROPRACTOR
Provider Other Organization Name Type Code:
3
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:
1326582008
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
762 160TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMMOND
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54015-5011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-963-2248
Provider Business Mailing Address Fax Number:
715-997-3019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
227 MERIDIAN DR
Provider Second Line Business Practice Location Address:
STE 4
Provider Business Practice Location Address City Name:
NEW RICHMOND
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54017-2565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-963-2248
Provider Business Practice Location Address Fax Number:
715-997-3019
Provider Enumeration Date:
12/14/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GONSOWSKI
Authorized Official First Name:
LEO
Authorized Official Middle Name:
RAYMOND
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
612-963-2248

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3847-012 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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