Provider Demographics
NPI:1447332051
Name:NIELSEN, LAWRENCE BLAIR (DC)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:BLAIR
Last Name:NIELSEN
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 1:5235 E SOUTHERN AVE
Mailing Address - Street 2:STE D106-438
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3626
Mailing Address - Country:US
Mailing Address - Phone:602-803-5032
Mailing Address - Fax:480-452-0921
Practice Address - Street 1:1910 S STAPLEY DR
Practice Address - Street 2:STE 221
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6680
Practice Address - Country:US
Practice Address - Phone:602-803-5032
Practice Address - Fax:480-386-5040
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4564111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ137696Medicaid