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General NPI Number Information
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NPI Number | 1710239264
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Entity Type | Organization
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Legal Business Name | LEIST, LTD.
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Dates
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Enumeration Date | 10/09/2012
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Last Update Date | 10/09/2012
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Provider Practice Location Address
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Address Line | 104 N GRANT ST
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City | OLNEY
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State | IL
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Zip | 62450-2612
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Country | US
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Telephone | 618-395-7246
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Fax | 618-395-7249
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Provider Business Mailing Address
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Address Line | 104 N GRANT ST
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City | OLNEY
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State | IL
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Zip | 62450-2612
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Country | US
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Telephone | 618-395-7246
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Fax | 618-395-7249
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DEREK ALAN LEIST
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Credential | D.C.
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Telephone | 314-954-1885
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | IL038012269
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License Number State | IL
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