Provider Demographics
NPI:1407251218
Name:LEO A. STATEN DC LLC
Entity Type:Organization
Organization Name:LEO A. STATEN DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIMITRA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:PALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-874-9084
Mailing Address - Street 1:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:LEDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07852-0051
Mailing Address - Country:US
Mailing Address - Phone:201-874-9084
Mailing Address - Fax:973-695-1933
Practice Address - Street 1:61 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:NEPTUNE CITY
Practice Address - State:NJ
Practice Address - Zip Code:07753-6426
Practice Address - Country:US
Practice Address - Phone:732-456-6337
Practice Address - Fax:973-695-1933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-23
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00631300111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ429838Medicare PIN
NJ429841Medicare PIN