Provider Demographics
NPI:1083719561
Name:COLEMAN, LYLE CHARLES (DC, DIBCN)
Entity Type:Individual
Prefix:DR
First Name:LYLE
Middle Name:CHARLES
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:DC, DIBCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-3959
Mailing Address - Country:US
Mailing Address - Phone:507-451-1654
Mailing Address - Fax:507-451-1655
Practice Address - Street 1:207 W HOLLY ST
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-3959
Practice Address - Country:US
Practice Address - Phone:507-451-1654
Practice Address - Fax:507-451-1655
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1245111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN905225900Medicaid
138401300OtherDOL PROVIDER NUMBER
MNT65411Medicare UPIN
MN905225900Medicaid