Provider Demographics
NPI:1336167493
Name:BANIC, LESLIE MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:MARIE
Last Name:BANIC
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 1:1505 NW GILMAN BLVD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5398
Mailing Address - Country:US
Mailing Address - Phone:425-313-9222
Mailing Address - Fax:425-313-9339
Practice Address - Street 1:1505 NW GILMAN BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5398
Practice Address - Country:US
Practice Address - Phone:425-313-9222
Practice Address - Fax:425-313-9339
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034311111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8802244Medicare ID - Type Unspecified
WAU99122Medicare UPIN