Provider Demographics
NPI:1144366881
Name:LEICHTER & PHELAN P.C.
Entity type:Organization
Organization Name:LEICHTER & PHELAN P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEICHTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:574-288-1234
Mailing Address - Street 1:1622 MISHAWAKA AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-1427
Mailing Address - Country:US
Mailing Address - Phone:574-288-1234
Mailing Address - Fax:574-288-4821
Practice Address - Street 1:1622 MISHAWAKA AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-1427
Practice Address - Country:US
Practice Address - Phone:574-288-1234
Practice Address - Fax:574-288-4821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN51000143A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100366010Medicaid
IN100366010Medicaid
IN164820Medicare PIN