Provider Demographics
NPI:1376606715
Name:LEBLANC, KYLE ANIELLO (DC)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:ANIELLO
Last Name:LEBLANC
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5809 S LINDBERGH BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-6948
Mailing Address - Country:US
Mailing Address - Phone:314-416-8334
Mailing Address - Fax:314-416-1199
Practice Address - Street 1:5809 S LINDBERGH BLVD STE B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-6948
Practice Address - Country:US
Practice Address - Phone:314-416-8334
Practice Address - Fax:314-416-1199
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003017106111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO182555OtherPROVIDER ID
MO165003583098OtherHUMANA PROVIDER ID
MO165003583098OtherHUMANA PROVIDER ID