Provider Demographics
NPI:1669471272
Name:GRGULA, LEISA MARIE MELODY (DC)
Entity type:Individual
Prefix:
First Name:LEISA MARIE
Middle Name:MELODY
Last Name:GRGULA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:LEISA MARIE
Other - Middle Name:MELODY
Other - Last Name:CHRABASZCZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:18261 N PIMA RD STE 115
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-6232
Mailing Address - Country:US
Mailing Address - Phone:602-493-2228
Mailing Address - Fax:602-493-2262
Practice Address - Street 1:18261 N PIMA RD STE 115
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-6232
Practice Address - Country:US
Practice Address - Phone:602-493-2228
Practice Address - Fax:602-493-2262
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDC5614111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0243640OtherBXBS
AZAZ0243640OtherBXBS
U64629Medicare UPIN