Provider Demographics
NPI:1407917883
Name:LEGANCHUK, MILTON (LAT)
Entity Type:Individual
Prefix:
First Name:MILTON
Middle Name:
Last Name:LEGANCHUK
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 N WISCONSIN DR
Mailing Address - Street 2:
Mailing Address - City:HOWARDS GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53083-1043
Mailing Address - Country:US
Mailing Address - Phone:920-207-0481
Mailing Address - Fax:
Practice Address - Street 1:2719 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5546
Practice Address - Country:US
Practice Address - Phone:920-683-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI680-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer