Provider Demographics
NPI:1982686309
Name:NELSON, LEE G (DC)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:G
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 1:1105 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52802-3512
Mailing Address - Country:US
Mailing Address - Phone:563-322-7052
Mailing Address - Fax:563-322-7052
Practice Address - Street 1:1105 W 4TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52802-3512
Practice Address - Country:US
Practice Address - Phone:563-322-7052
Practice Address - Fax:563-322-7052
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-20
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04883111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA19950OtherBLUE CROSS BLUE SHIELD
IA0199505Medicaid
IA19950OtherBLUE CROSS BLUE SHIELD
IAT01144Medicare UPIN