Provider Demographics
NPI:1457539827
Name:LIESER, CHAD DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:DAVID
Last Name:LIESER
Suffix:
Gender:M
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:PO BOX 277
Mailing Address - Street 2:29 LAKE ST. S.
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-0277
Mailing Address - Country:US
Mailing Address - Phone:763-263-3470
Mailing Address - Fax:763-263-5900
Practice Address - Street 1:29 LAKE ST S
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-4588
Practice Address - Country:US
Practice Address - Phone:763-263-3470
Practice Address - Fax:763-263-5900
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5418111N00000X
MN4288111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO510578Medicare PIN