Provider Demographics
NPI:1568541118
Name:LEAVITT, CLARENCE NATHAN JR (DC)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:NATHAN
Last Name:LEAVITT
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:ROCKY
Other - Middle Name:
Other - Last Name:LEAVITT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:1842 IRON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4646
Mailing Address - Country:US
Mailing Address - Phone:360-676-9533
Mailing Address - Fax:360-647-8711
Practice Address - Street 1:1842 IRON ST
Practice Address - Street 2:SUITE A
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4646
Practice Address - Country:US
Practice Address - Phone:360-676-9533
Practice Address - Fax:360-647-8711
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2163111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2007953Medicaid
WA14434OtherL & I
WA2007953Medicaid