Provider Demographics
NPI:1851389167
Name:GONSOWSKI, LEO RAYMOND III (DC, CSCS)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:RAYMOND
Last Name:GONSOWSKI
Suffix:III
Gender:M
Credentials:DC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 S ARCH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-1832
Mailing Address - Country:US
Mailing Address - Phone:715-246-5600
Mailing Address - Fax:715-246-5806
Practice Address - Street 1:471 S ARCH AVE
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-1832
Practice Address - Country:US
Practice Address - Phone:715-246-5600
Practice Address - Fax:715-246-5806
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3847-012111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI666234OtherCHIROCARE WISCONSIN
MN2C933GOOtherBLUE CROSS & BLUE SHIELD
WI666234OtherCHIROCARE WISCONSIN