Provider Demographics
NPI:1811705122
Name:CHISHOLM, LESLIE LEE IV (DC)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:LEE
Last Name:CHISHOLM
Suffix:IV
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 1:17167 HALLANDALE LOOP APT 210
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-8254
Mailing Address - Country:US
Mailing Address - Phone:813-475-1387
Mailing Address - Fax:
Practice Address - Street 1:8466 NORTHCLIFFE BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-1140
Practice Address - Country:US
Practice Address - Phone:352-666-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15286111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor