1962416867 NPI number — DR. NICOLE LEIGH SDAO D.C.

Table of content: DR. NICOLE LEIGH SDAO D.C. (NPI 1962416867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962416867 NPI number — DR. NICOLE LEIGH SDAO D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SDAO
Provider First Name:
NICOLE
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BAHNUB
Provider Other First Name:
NICOLE
Provider Other Middle Name:
LEIGH
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.C.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962416867
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 W STEPHENSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREEPORT
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61032-5001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-232-4217
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 W STEPHENSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREEPORT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61032-5001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-232-4217
Provider Business Practice Location Address Fax Number:
815-233-3379
Provider Enumeration Date:
07/28/2006

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: 111NX0800X , with the licence number:  038-008743 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08925958 . This is a "BLUE CROSS BLUE SHEILD #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 350049409 . This is a "MEDICARE RAILROAD #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 36-3581491 . This is a "ICHP TAX I.D. #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 75-3157454 . This is a "PRACTICE CORP. TAX I.D.#" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 038-008743 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: K13271 . This is a "MEDICARE MEMBER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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