Provider Demographics
NPI:1326582008
Name:DOCTORLEO LLC
Entity type:Organization
Organization Name:DOCTORLEO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:GONSOWSKI
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:612-963-2248
Mailing Address - Street 1:762 160TH ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54015-5011
Mailing Address - Country:US
Mailing Address - Phone:612-963-2248
Mailing Address - Fax:715-997-3019
Practice Address - Street 1:227 MERIDIAN DR
Practice Address - Street 2:STE 4
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-2565
Practice Address - Country:US
Practice Address - Phone:612-963-2248
Practice Address - Fax:715-997-3019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-14
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3847-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty