Provider Demographics
NPI:1710996418
Name:WARD, LEONARD EDWIN (DC)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:EDWIN
Last Name:WARD
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 1:122 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-1143
Mailing Address - Country:US
Mailing Address - Phone:208-852-0083
Mailing Address - Fax:208-852-0051
Practice Address - Street 1:122 N STATE ST
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1143
Practice Address - Country:US
Practice Address - Phone:208-852-0083
Practice Address - Fax:208-852-0051
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-487111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010008535OtherBLUE SHEILD
IDC4876OtherBLUE CROSS
ID1671837Medicare ID - Type Unspecified
IDT44492Medicare UPIN