Provider Demographics
NPI:1720120876
Name:LEROY, NICHOLAS ROGER (DC)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ROGER
Last Name:LEROY
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 1:1002 W. LAKE STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607
Mailing Address - Country:US
Mailing Address - Phone:312-243-3338
Mailing Address - Fax:
Practice Address - Street 1:1002 W. LAKE STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607
Practice Address - Country:US
Practice Address - Phone:312-243-3338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-007739111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001607135OtherBCBS
WI457811OtherBLUE CROSS BLUE SHIELD
IL372681Medicare PIN
WI457811OtherBLUE CROSS BLUE SHIELD
WI372681Medicare ID - Type Unspecified
IL372681001Medicare PIN