Provider Demographics
NPI:1972595213
Name:MCLEOD, GARY ROSS (DC)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROSS
Last Name:MCLEOD
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:PO BOX 447
Mailing Address - Street 2:1107 W. BROADWAY STREET
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-0447
Mailing Address - Country:US
Mailing Address - Phone:269-273-6712
Mailing Address - Fax:269-273-3436
Practice Address - Street 1:1107 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-9362
Practice Address - Country:US
Practice Address - Phone:269-273-6712
Practice Address - Fax:269-273-3436
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2012-08-21
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
MI2301004587111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2119428Medicaid
MI2119428Medicaid
MIT33591Medicare UPIN