Healthcare Provider Details

I. General information

NPI: 1922069699
Provider Name (Legal Business Name): KIM M LEIS-KEELING D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 WESTERN AVE
ALBANY NY
12203-5069
US

IV. Provider business mailing address

2021 WESTERN AVE STE 102
ALBANY NY
12203-5029
US

V. Phone/Fax

Practice location:
  • Phone: 518-869-3415
  • Fax:
Mailing address:
  • Phone: 518-982-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4498
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberX012138-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: