Provider Demographics
NPI:1154432870
Name:LEROUX, MICHAEL G (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:LEROUX
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 1:1920 MINERAL SPRING AVE UNIT 16
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-3742
Mailing Address - Country:US
Mailing Address - Phone:401-354-5500
Mailing Address - Fax:401-354-7470
Practice Address - Street 1:2001 SW 80TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34481-1544
Practice Address - Country:US
Practice Address - Phone:858-752-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC30201111N00000X
RIDCP00381111N00000X
FLCH13656111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0302010OtherBLUE SHIELD
RI29841OtherBLUE SHIEL D PROVIDER #
FLCH13656OtherSTATE OF FL DEPARTMENT OF HEALTH
RI29841OtherBLUE SHIEL D PROVIDER #