Provider Demographics
NPI:1215128889
Name:PHILLIP K. LEBLANC
Entity type:Organization
Organization Name:PHILLIP K. LEBLANC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:LEBLANC
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:409-833-3080
Mailing Address - Street 1:1595 CORNERSTONE CT STE A
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-3899
Mailing Address - Country:US
Mailing Address - Phone:409-833-3080
Mailing Address - Fax:409-833-9343
Practice Address - Street 1:1595 CORNERSTONE CT STE A
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-3899
Practice Address - Country:US
Practice Address - Phone:409-833-3080
Practice Address - Fax:409-833-9343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9459111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164324901Medicaid
TX164324901Medicaid