Provider Demographics
NPI:1477221042
Name:LAX, NATHAN (DC)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:LAX
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 1:222 SUMMER ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-2365
Mailing Address - Country:US
Mailing Address - Phone:802-748-3166
Mailing Address - Fax:802-424-1611
Practice Address - Street 1:222 SUMMER ST STE 101
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-2365
Practice Address - Country:US
Practice Address - Phone:802-748-3166
Practice Address - Fax:802-424-1611
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VTY100388022111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor