Provider Demographics
NPI:1558350546
Name:FORMANEK, LARRY M (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:M
Last Name:FORMANEK
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 1:115 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50138-2525
Mailing Address - Country:US
Mailing Address - Phone:641-842-3007
Mailing Address - Fax:641-842-5612
Practice Address - Street 1:115 E MAIN ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:IA
Practice Address - Zip Code:50138-2525
Practice Address - Country:US
Practice Address - Phone:641-842-3007
Practice Address - Fax:641-842-5612
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAAO5434111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0285262Medicaid
IA6599OtherMIDLANDS CHOICE
IAT86264Medicare UPIN
IAI10557Medicare ID - Type Unspecified