Provider Demographics
NPI:1255680021
Name:LEESBURG CHIROPRACTIC CENTER, INC
Entity Type:Organization
Organization Name:LEESBURG CHIROPRACTIC CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-787-4500
Mailing Address - Street 1:1107 W NORTH BLVD
Mailing Address - Street 2:#23
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748
Mailing Address - Country:US
Mailing Address - Phone:352-787-4500
Mailing Address - Fax:352-787-8955
Practice Address - Street 1:1107 W NORTH BLVD
Practice Address - Street 2:#23
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748
Practice Address - Country:US
Practice Address - Phone:352-787-4500
Practice Address - Fax:352-787-8955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0005771111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051041600Medicaid
FL22269Medicare PIN
T54847Medicare UPIN