Provider Demographics
NPI:1235449513
Name:HAACK, LEILANI JAN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:LEILANI
Middle Name:JAN
Last Name:HAACK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 N. 14TH ST.
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503
Mailing Address - Country:US
Mailing Address - Phone:701-751-3070
Mailing Address - Fax:701-751-3071
Practice Address - Street 1:3000 N. 14TH ST.
Practice Address - Street 2:SUITE 3A
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503
Practice Address - Country:US
Practice Address - Phone:701-751-3070
Practice Address - Fax:701-751-3071
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND831171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor