Provider Demographics
NPI:1164561452
Name:DEWITT, LEROY O III (DC)
Entity Type:Individual
Prefix:DR
First Name:LEROY
Middle Name:O
Last Name:DEWITT
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1070 W 1600 S
Mailing Address - Street 2:STE A102
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5569
Mailing Address - Country:US
Mailing Address - Phone:435-688-9551
Mailing Address - Fax:435-215-2450
Practice Address - Street 1:1067 E TABERNACLE ST STE 4
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-6771
Practice Address - Country:US
Practice Address - Phone:435-688-9551
Practice Address - Fax:435-688-9192
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4879417-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057243Medicare PIN
UTU94879Medicare UPIN