Provider Demographics
NPI:1063078871
Name:HANSEN, BRIAN THOMAS (DC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:THOMAS
Last Name:HANSEN
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 1:1920 RUE ST STE 11
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-3601
Mailing Address - Country:US
Mailing Address - Phone:712-323-6824
Mailing Address - Fax:
Practice Address - Street 1:1920 RUE ST STE 11
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-3601
Practice Address - Country:US
Practice Address - Phone:712-323-6824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA095690111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1164875092Medicaid