Healthcare Provider Details

I. General information

NPI: 1861440091
Provider Name (Legal Business Name): LEALAND K FAGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E RUTHERFORD ST
LANDRUM SC
29356-1725
US

IV. Provider business mailing address

PO BOX 207 900 E RUTHERFORD ST
LANDRUM SC
29356-0207
US

V. Phone/Fax

Practice location:
  • Phone: 864-316-4611
  • Fax:
Mailing address:
  • Phone: 864-316-4611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2661
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: