Healthcare Provider Details

I. General information

NPI: 1093017303
Provider Name (Legal Business Name): ALLEN COUNTY CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2010
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6320 CONSTITUTION DR
FORT WAYNE IN
46804-1518
US

IV. Provider business mailing address

6320 CONSTITUTION DR
FORT WAYNE IN
46804-1518
US

V. Phone/Fax

Practice location:
  • Phone: 260-432-7339
  • Fax:
Mailing address:
  • Phone: 260-432-7339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number
License Number StateIN

VIII. Authorized Official

Name: DR. MONIQUE LILLIAN MARIE LEVESQUE-HARTLE
Title or Position: PRESIDENT
Credential: D.C.
Phone: 260-432-7339