Provider Demographics
NPI:1013339233
Name:LEGG, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:LEGG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 W BASELINE RD
Mailing Address - Street 2:1035
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1169
Mailing Address - Country:US
Mailing Address - Phone:217-653-1195
Mailing Address - Fax:
Practice Address - Street 1:250 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1262
Practice Address - Country:US
Practice Address - Phone:480-785-1355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8366111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor