Provider Demographics
NPI:1467428409
Name:QUIRAM, LESLIE R (DC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:R
Last Name:QUIRAM
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 1:2412 E WASHINGTON ST
Mailing Address - Street 2:SUITE 9A
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4497
Mailing Address - Country:US
Mailing Address - Phone:309-662-6462
Mailing Address - Fax:309-663-8812
Practice Address - Street 1:2412 E WASHINGTON ST
Practice Address - Street 2:SUITE 9A
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4497
Practice Address - Country:US
Practice Address - Phone:309-662-6462
Practice Address - Fax:309-663-8812
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5732002OtherBCBS PPO PROVIDER #
ILK45356Medicare PIN