Provider Demographics
NPI:1811030778
Name:LEO JOHN MELTVEDT JR DC
Entity Type:Organization
Organization Name:LEO JOHN MELTVEDT JR DC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MELTVEDT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:619-521-3151
Mailing Address - Street 1:4202 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-2516
Mailing Address - Country:US
Mailing Address - Phone:619-521-3151
Mailing Address - Fax:619-516-3846
Practice Address - Street 1:4202 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-2516
Practice Address - Country:US
Practice Address - Phone:619-521-3151
Practice Address - Fax:619-516-3846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26574111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0265740OtherBLUE SHIELD OF CALIFORNIA
CADC0265740OtherBLUE SHIELD OF CALIFORNIA