Provider Demographics
NPI:1417085408
Name:CROCKETT, LAWRENCE W (DC)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:W
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:LAWRENCE
Other - Middle Name:W
Other - Last Name:CROCKETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:671 OHIO PIKE STE D
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45245-2136
Mailing Address - Country:US
Mailing Address - Phone:412-760-5760
Mailing Address - Fax:513-752-7728
Practice Address - Street 1:671 OHIO PIKE STE D
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-2136
Practice Address - Country:US
Practice Address - Phone:412-760-5760
Practice Address - Fax:513-752-7728
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2402111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor