Provider Demographics
NPI:1639565021
Name:LEISEY, TRENT (DC)
Entity Type:Individual
Prefix:DR
First Name:TRENT
Middle Name:
Last Name:LEISEY
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 1:2947 N ASHLEY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1706
Mailing Address - Country:US
Mailing Address - Phone:843-815-3341
Mailing Address - Fax:
Practice Address - Street 1:2947 N ASHLEY ST
Practice Address - Street 2:SUITE A
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1706
Practice Address - Country:US
Practice Address - Phone:843-815-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3998111N00000X
GACHIR009581111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor