Provider Demographics
NPI:1619177078
Name:LEEDLE CHIROPRACTIC CLINIC P C
Entity Type:Organization
Organization Name:LEEDLE CHIROPRACTIC CLINIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEEDLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:810-632-7700
Mailing Address - Street 1:11460 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48353-2736
Mailing Address - Country:US
Mailing Address - Phone:810-632-7700
Mailing Address - Fax:810-632-9770
Practice Address - Street 1:11460 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:MI
Practice Address - Zip Code:48353-2736
Practice Address - Country:US
Practice Address - Phone:810-632-7700
Practice Address - Fax:810-632-9770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI095579261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI123473OtherCARE CHOICES ID #
MI123473OtherPREFERRED CHOICES ID #
MIT33187OtherBC BS UPIN
MI290825Medicaid
MI123473OtherCARE CHOICES ID #