Provider Demographics
NPI:1669744306
Name:BOTTA, LESLIE J (DC)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:J
Last Name:BOTTA
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 1:43 W SECOND ST
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-1240
Mailing Address - Country:US
Mailing Address - Phone:815-200-4362
Mailing Address - Fax:
Practice Address - Street 1:43 W SECOND ST
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-1240
Practice Address - Country:US
Practice Address - Phone:815-200-4362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007407-1111N00000X
IL038012127111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor