Provider Demographics
NPI:1205933165
Name:ALLEN COUNTY FAMILY & SPORTS CHIROPRACTIC
Entity type:Organization
Organization Name:ALLEN COUNTY FAMILY & SPORTS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:LILLIAN MARIE
Authorized Official - Last Name:LEVESQUE-HARTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:260-432-7339
Mailing Address - Street 1:3835 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6809
Mailing Address - Country:US
Mailing Address - Phone:260-432-7339
Mailing Address - Fax:
Practice Address - Street 1:3835 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6809
Practice Address - Country:US
Practice Address - Phone:260-432-7339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001638111NN1001X
IN08001622111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
Not Answered111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty