=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417260779
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLMAR CHIROPRACTIC CLINIC P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2010
-----------------------------------------------------
Last Update Date | 07/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1950 19TH AVE SW
-----------------------------------------------------
City | WILLMAR
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56201-4925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-235-7347
-----------------------------------------------------
Fax | 320-222-2826
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1950 19TH AVE SW
-----------------------------------------------------
City | WILLMAR
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56201-4925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-235-7347
-----------------------------------------------------
Fax | 320-222-2826
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CRAIG MATTHEW LEIS
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 320-235-7347
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2839
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------