Provider Demographics
NPI:1245451442
Name:LIGHTFOOT, NICHOLAS AUSTIN
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:AUSTIN
Last Name:LIGHTFOOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 N WALNUT ST
Mailing Address - Street 2:STE. B
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3809
Mailing Address - Country:US
Mailing Address - Phone:812-333-9404
Mailing Address - Fax:812-333-2152
Practice Address - Street 1:532 N WALNUT ST
Practice Address - Street 2:STE. B
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3809
Practice Address - Country:US
Practice Address - Phone:812-333-9404
Practice Address - Fax:812-333-2152
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001909A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000079774OtherANTHEM BLUE CROSS
IN200270020AMedicaid
IN000000079774OtherANTHEM BLUE CROSS
IN200270020AMedicaid