Provider Demographics
NPI:1164617171
Name:LEAVENGOOD CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:LEAVENGOOD CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:LINDELIE
Authorized Official - Last Name:LEAVENGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:478-988-4663
Mailing Address - Street 1:1238 S HOUSTON LAKE RD
Mailing Address - Street 2:STE 3
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-0723
Mailing Address - Country:US
Mailing Address - Phone:478-988-4663
Mailing Address - Fax:478-988-4881
Practice Address - Street 1:1238 S HOUSTON LAKE RD
Practice Address - Street 2:STE 3
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-0723
Practice Address - Country:US
Practice Address - Phone:478-988-4663
Practice Address - Fax:478-988-4881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2823111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00490421AMedicaid
GA1346304078OtherINDIVIUAL NPI
GAU29808Medicare UPIN
GA35ZCHLFMedicare PIN