Provider Demographics
NPI:1518986264
Name:NELSON, LARRY D (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:NELSON
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 1:2585 CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7516
Mailing Address - Country:US
Mailing Address - Phone:208-522-0200
Mailing Address - Fax:208-523-6051
Practice Address - Street 1:2585 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7516
Practice Address - Country:US
Practice Address - Phone:208-522-0200
Practice Address - Fax:208-523-6051
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA631111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID350035586OtherPALMETTO RAILROAD
ID000010020547OtherBLUE SHIELD
IDC9453OtherBLUE CROSS
IDU25028Medicare UPIN
ID1672597Medicare ID - Type Unspecified