Provider Demographics
NPI:1134222706
Name:VAN DEUSEN, LESLIE (DC)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:
Last Name:VAN DEUSEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MS
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:TALLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1500 ADAMS AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3819
Mailing Address - Country:US
Mailing Address - Phone:949-584-9888
Mailing Address - Fax:714-242-1925
Practice Address - Street 1:1500 ADAMS AVE STE 306
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3819
Practice Address - Country:US
Practice Address - Phone:949-584-9888
Practice Address - Fax:714-242-1925
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28754111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWDC28754AMedicare ID - Type Unspecified