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General NPI Number Information
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NPI Number | 1043438476
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Entity Type | Organization
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Legal Business Name | LEADING EDGE HEALTH & WELLNESS DIAGNOSTIC CENTER
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Dates
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Enumeration Date | 04/23/2007
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Last Update Date | 12/26/2008
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Provider Practice Location Address
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Address Line | 1013 LIBERTY ST
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City | MORRIS
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State | IL
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Zip | 60450-1510
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Country | US
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Telephone | 815-941-5117
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Fax | 815-941-5118
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Provider Business Mailing Address
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Address Line | 1013 LIBERTY ST
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City | MORRIS
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State | IL
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Zip | 60450-1510
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Country | US
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Telephone | 815-941-5117
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Fax | 815-941-5118
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TERRI JO GILLETTE
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Credential | DC
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Telephone | 815-941-5117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 038010842
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License Number State | IL
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