Provider Demographics
NPI:1437236312
Name:LEAVITT, RICHARD WALLACE (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WALLACE
Last Name:LEAVITT
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 162
Mailing Address - Street 2:
Mailing Address - City:SPRINGER
Mailing Address - State:OK
Mailing Address - Zip Code:73458-0162
Mailing Address - Country:US
Mailing Address - Phone:580-768-5676
Mailing Address - Fax:
Practice Address - Street 1:16230 STATE HIGHWAY 53
Practice Address - Street 2:
Practice Address - City:SPRINGER
Practice Address - State:OK
Practice Address - Zip Code:73458-8248
Practice Address - Country:US
Practice Address - Phone:580-768-5676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05914111N00000X
OK4319111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0188219Medicaid
IA0188219Medicaid
IA47615Medicare ID - Type Unspecified