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General NPI Number Information
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NPI Number | 1326582008
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Entity Type | Organization
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Legal Business Name | DOCTORLEO LLC
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Dates
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Enumeration Date | 12/14/2016
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Last Update Date | 01/03/2018
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Provider Practice Location Address
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Address Line | 227 MERIDIAN DR STE 4
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City | NEW RICHMOND
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State | WI
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Zip | 54017-2565
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Country | US
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Telephone | 612-963-2248
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Fax | 715-997-3019
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Provider Business Mailing Address
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Address Line | 762 160TH ST
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City | HAMMOND
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State | WI
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Zip | 54015-5011
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Country | US
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Telephone | 612-963-2248
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Fax | 715-997-3019
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Authorized Official
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Title or Position | OWNER
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Name | DR. LEO RAYMOND GONSOWSKI III
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Credential | D.C
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Telephone | 612-963-2248
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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 | 3847-012
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License Number State | WI
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