Provider Demographics
NPI:1598068439
Name:LIVING WELL CHIROPRACTIC, P.C.
Entity Type:Organization
Organization Name:LIVING WELL CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-230-7333
Mailing Address - Street 1:3140 HARBOR LANE N.
Mailing Address - Street 2:SUITE #102
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-5118
Mailing Address - Country:US
Mailing Address - Phone:763-230-7333
Mailing Address - Fax:763-230-7335
Practice Address - Street 1:3140 HARBOR LN N
Practice Address - Street 2:SUITE #102
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5126
Practice Address - Country:US
Practice Address - Phone:763-230-7333
Practice Address - Fax:763-230-7335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4513111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU98739Medicare UPIN