Provider Demographics
NPI:1043830946
Name:LEACH CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:LEACH CHIROPRACTIC CLINIC LLC
Other - Org Name:LEACH CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:662-352-4004
Mailing Address - Street 1:PO BOX 80121
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-0121
Mailing Address - Country:US
Mailing Address - Phone:662-323-2371
Mailing Address - Fax:662-323-2382
Practice Address - Street 1:214 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3381
Practice Address - Country:US
Practice Address - Phone:662-323-2371
Practice Address - Fax:662-323-2382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-21
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05303732Medicaid