Provider Demographics
NPI:1710239264
Name:LEIST, LTD.
Entity Type:Organization
Organization Name:LEIST, LTD.
Other - Org Name:PERFORMANCE CHIROPRACTIC AND SPORTS REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:LEIST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-954-1885
Mailing Address - Street 1:104 N GRANT ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2612
Mailing Address - Country:US
Mailing Address - Phone:618-395-7246
Mailing Address - Fax:618-395-7249
Practice Address - Street 1:104 N GRANT ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2612
Practice Address - Country:US
Practice Address - Phone:618-395-7246
Practice Address - Fax:618-395-7249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL038012269261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center