Provider Demographics
NPI:1861440091
Name:FAGAN, LEALAND K
Entity type:Individual
Prefix:
First Name:LEALAND
Middle Name:K
Last Name:FAGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:900 E RUTHERFORD ST
Mailing Address - City:LANDRUM
Mailing Address - State:SC
Mailing Address - Zip Code:29356-0207
Mailing Address - Country:US
Mailing Address - Phone:864-316-4611
Mailing Address - Fax:
Practice Address - Street 1:900 E RUTHERFORD ST
Practice Address - Street 2:
Practice Address - City:LANDRUM
Practice Address - State:SC
Practice Address - Zip Code:29356-1725
Practice Address - Country:US
Practice Address - Phone:864-316-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2661111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor