Provider Demographics
NPI:1780644195
Name:CROCKETT, LANNY CRAIG (DC)
Entity Type:Individual
Prefix:DR
First Name:LANNY
Middle Name:CRAIG
Last Name:CROCKETT
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 1:1300 S MAIN ST
Mailing Address - Street 2:STE A
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-5662
Mailing Address - Country:US
Mailing Address - Phone:928-536-5525
Mailing Address - Fax:928-484-6070
Practice Address - Street 1:1300 S MAIN ST
Practice Address - Street 2:STE A
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5662
Practice Address - Country:US
Practice Address - Phone:928-536-5525
Practice Address - Fax:928-484-6070
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7414111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0939810OtherBLUE CROSS BLUE SHIELD AZ
AZ841595Medicaid
AZAZ0939810OtherBLUE CROSS BLUE SHIELD AZ
AZ841595Medicaid