Provider Demographics
NPI:1518936210
Name:NICKELSON, LARRY (DC)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:NICKELSON
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 1:207 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MILLER
Mailing Address - State:SD
Mailing Address - Zip Code:57362-1426
Mailing Address - Country:US
Mailing Address - Phone:605-853-2230
Mailing Address - Fax:605-853-3111
Practice Address - Street 1:207 E 3RD ST
Practice Address - Street 2:
Practice Address - City:MILLER
Practice Address - State:SD
Practice Address - Zip Code:57362-1426
Practice Address - Country:US
Practice Address - Phone:605-853-2230
Practice Address - Fax:605-853-3111
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD638111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4999757OtherBSSD
SD4999850OtherBSSD
SD7602082Medicaid
SD512482OtherAMPPO
SD7602080Medicaid
SD0080147OtherBSSD
SD7602083Medicaid
SD7602085Medicaid
SD4999860OtherBSSD
SD0006716OtherBSSD
SD7602084Medicaid
SD512482OtherAMPPO
SD4999757OtherBSSD
SD350034689Medicare PIN
SDT66545Medicare UPIN
SD7602084Medicaid
SD7602083Medicaid