Provider Demographics
NPI:1659374064
Name:LEBLANC, RUSSELL A (DC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:A
Last Name:LEBLANC
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 1:5585 E HOHNKE RD
Mailing Address - Street 2:
Mailing Address - City:CEDAR
Mailing Address - State:MI
Mailing Address - Zip Code:49621-9607
Mailing Address - Country:US
Mailing Address - Phone:231-256-2558
Mailing Address - Fax:
Practice Address - Street 1:489 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE LEELANAU
Practice Address - State:MI
Practice Address - Zip Code:49653-9740
Practice Address - Country:US
Practice Address - Phone:231-256-7877
Practice Address - Fax:231-256-9529
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006832111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2694706Medicaid
MI950D510120OtherBLUE CROSS AND BLUE SHIELD OF MICHIGAN
MIU21811Medicare UPIN
MI0D55111Medicare PIN