Provider Demographics
NPI:1508406554
Name:LIFORD, NICHOLAS J (DC)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:J
Last Name:LIFORD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1026 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-2125
Mailing Address - Country:US
Mailing Address - Phone:636-358-1905
Mailing Address - Fax:
Practice Address - Street 1:3899 MID RIVERS MALL DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2870
Practice Address - Country:US
Practice Address - Phone:636-936-3613
Practice Address - Fax:936-936-8069
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2021-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019046195207T00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1508406554Medicaid