Provider Demographics
NPI:1548602469
Name:LESLEY M. HEIDRICH ACUPUNCTURE, LLC TM
Entity type:Organization
Organization Name:LESLEY M. HEIDRICH ACUPUNCTURE, LLC TM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HEIDRICH
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, CMLDT
Authorized Official - Phone:773-295-7319
Mailing Address - Street 1:2140 W IRVING PARK RD
Mailing Address - Street 2:#1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:773-857-2415
Practice Address - Street 1:6374 N LINCOLN AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-1275
Practice Address - Country:US
Practice Address - Phone:773-295-7319
Practice Address - Fax:773-857-2415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-19
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001097171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty