Provider Demographics
NPI:1255496162
Name:BETTENCOURT, LEILANI (DC)
Entity Type:Individual
Prefix:DR
First Name:LEILANI
Middle Name:
Last Name:BETTENCOURT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 WESTWOOD DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-5114
Mailing Address - Country:US
Mailing Address - Phone:408-448-0505
Mailing Address - Fax:408-448-0504
Practice Address - Street 1:1620 WESTWOOD DR
Practice Address - Street 2:SUITE D
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-5114
Practice Address - Country:US
Practice Address - Phone:408-448-0505
Practice Address - Fax:408-448-0504
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29239111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADCO292390Medicare PIN
CAV01686Medicare UPIN