Provider Demographics
NPI:1962604652
Name:BELLWOOD, LESLIE WALTON JR (DC)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:WALTON
Last Name:BELLWOOD
Suffix:JR
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 1:8645 HAVEN AVE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4818
Mailing Address - Country:US
Mailing Address - Phone:909-941-0633
Mailing Address - Fax:909-945-5372
Practice Address - Street 1:8645 HAVEN AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4818
Practice Address - Country:US
Practice Address - Phone:909-941-0633
Practice Address - Fax:909-945-5372
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10130111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor