Provider Demographics
NPI:1295050516
Name:WALLEN, LAWRENCE CLIFFORD III (DC)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:CLIFFORD
Last Name:WALLEN
Suffix:III
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 1:21740 S TAMIAMI TRL
Mailing Address - Street 2:#103
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-2819
Mailing Address - Country:US
Mailing Address - Phone:239-676-9116
Mailing Address - Fax:
Practice Address - Street 1:21740 S TAMIAMI TRL
Practice Address - Street 2:#103
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-2819
Practice Address - Country:US
Practice Address - Phone:239-676-9116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009662111N00000X
FLCH10733111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008271600Medicaid
FL008271600Medicaid