Provider Demographics
NPI:1831260876
Name:LEANNA, RANDALL R (DC)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:R
Last Name:LEANNA
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 250
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:WI
Mailing Address - Zip Code:53156-0250
Mailing Address - Country:US
Mailing Address - Phone:262-495-4428
Mailing Address - Fax:262-495-4480
Practice Address - Street 1:212 W. MAIN ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:WI
Practice Address - Zip Code:53156-0250
Practice Address - Country:US
Practice Address - Phone:262-495-4428
Practice Address - Fax:262-495-4480
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2787 - 012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU25320Medicare UPIN
WI000070323Medicare ID - Type Unspecified