Provider Demographics
NPI:1780852574
Name:MICHELLE LEACH CHIROPRACTIC CORP
Entity Type:Organization
Organization Name:MICHELLE LEACH CHIROPRACTIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:858-578-2070
Mailing Address - Street 1:9474 KEARNY VILLA ROAD
Mailing Address - Street 2:#113
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126
Mailing Address - Country:US
Mailing Address - Phone:858-578-2070
Mailing Address - Fax:858-578-2722
Practice Address - Street 1:9474 KEARNY VILLA ROAD
Practice Address - Street 2:#113
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126
Practice Address - Country:US
Practice Address - Phone:858-578-2070
Practice Address - Fax:858-578-2722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC272540111N00000X
CAAC 11426171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0272540OtherBLUESHIELD