Provider Demographics
NPI:1710062708
Name:LEACH, BRANDIE LYN (DC)
Entity Type:Individual
Prefix:
First Name:BRANDIE
Middle Name:LYN
Last Name:LEACH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 N. MO PAC EXPRESSWAY
Mailing Address - Street 2:BLD 3, STE 3101
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731
Mailing Address - Country:US
Mailing Address - Phone:512-491-7772
Mailing Address - Fax:512-339-6806
Practice Address - Street 1:6500 N. MO PAC EXPRESSWAY
Practice Address - Street 2:BLD 3, STE 3101
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731
Practice Address - Country:US
Practice Address - Phone:512-491-7772
Practice Address - Fax:512-339-6806
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9175111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8A1003Medicare ID - Type Unspecified
TXU92469Medicare UPIN