Provider Demographics
NPI:1134125768
Name:MIKKELSON, LAWRENCE R (DC)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:R
Last Name:MIKKELSON
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 1:8131 US HIGHWAY 42
Mailing Address - Street 2:P O BOX 547
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-9634
Mailing Address - Country:US
Mailing Address - Phone:859-525-7117
Mailing Address - Fax:859-282-3343
Practice Address - Street 1:8131 US HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-9634
Practice Address - Country:US
Practice Address - Phone:859-525-7117
Practice Address - Fax:859-282-3343
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4396111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85002756Medicaid
KY0528001Medicare PIN
KY85002756Medicaid