Provider Demographics
NPI:1073836342
Name:LEIST, DEREK ALAN (DC)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:ALAN
Last Name:LEIST
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 WARD CIR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7551
Mailing Address - Country:US
Mailing Address - Phone:615-636-5923
Mailing Address - Fax:615-915-3187
Practice Address - Street 1:204 WARD CIR
Practice Address - Street 2:SUITE 300
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7551
Practice Address - Country:US
Practice Address - Phone:615-636-5923
Practice Address - Fax:615-915-3187
Is Sole Proprietor?:No
Enumeration Date:2010-03-01
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2649111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2649OtherSTATE LICENSE #