Healthcare Provider Details

I. General information

NPI: 1720120876
Provider Name (Legal Business Name): NICHOLAS ROGER LEROY D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 W. LAKE STREET
CHICAGO IL
60607
US

IV. Provider business mailing address

1002 W. LAKE STREET
CHICAGO IL
60607
US

V. Phone/Fax

Practice location:
  • Phone: 312-243-3338
  • Fax:
Mailing address:
  • Phone: 312-243-3338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number038-007739
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: