Provider Demographics
NPI:1932385838
Name:DE LEEUW IV, WARNER (DC)
Entity Type:Individual
Prefix:DR
First Name:WARNER
Middle Name:
Last Name:DE LEEUW IV
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 1:0-81 LAKE MICHIGAN DRIVE, NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-8722
Mailing Address - Country:US
Mailing Address - Phone:616-243-1444
Mailing Address - Fax:616-243-2434
Practice Address - Street 1:0-81 LAKE MICHIGAN DRIVE, NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-8722
Practice Address - Country:US
Practice Address - Phone:616-243-1444
Practice Address - Fax:616-243-2434
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009355111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
P57110001OtherMEDICARE PTAN