Provider Demographics
NPI:1255331393
Name:BOUMA, LAWRENCE (DC)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:BOUMA
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 1:102 CHRISTY PARK DR
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-1584
Mailing Address - Country:US
Mailing Address - Phone:724-465-4080
Mailing Address - Fax:724-465-6923
Practice Address - Street 1:102 CHRISTY PARK DR
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-1584
Practice Address - Country:US
Practice Address - Phone:724-465-4080
Practice Address - Fax:724-465-6923
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC 001387 L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA251320815Medicare UPIN