Provider Demographics
NPI:1912924655
Name:BOISVERT, LEO R (DC)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:R
Last Name:BOISVERT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MALABU DR
Mailing Address - Street 2:SUITE #10
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3141
Mailing Address - Country:US
Mailing Address - Phone:859-277-7521
Mailing Address - Fax:859-275-2020
Practice Address - Street 1:101 MALABU DR
Practice Address - Street 2:SUITE #10
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3141
Practice Address - Country:US
Practice Address - Phone:859-277-7521
Practice Address - Fax:859-275-2020
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5052111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017382990001Medicaid
80898453Medicare ID - Type Unspecified