Provider Demographics
NPI:1922069699
Name:LEIS-KEELING, KIM M (DC)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:M
Last Name:LEIS-KEELING
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 WESTERN AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-5029
Mailing Address - Country:US
Mailing Address - Phone:518-982-0200
Mailing Address - Fax:
Practice Address - Street 1:2021 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-5069
Practice Address - Country:US
Practice Address - Phone:518-869-3415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4498111N00000X
NYX012138-1111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FM210K8LEOtherBCBS
NY45-4547459OtherCHIROPRACTIC
FM210K8LEOtherBCBS