Provider Demographics
NPI:1346234846
Name:NISSEN, LYLE D (DC)
Entity type:Individual
Prefix:DR
First Name:LYLE
Middle Name:D
Last Name:NISSEN
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:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:SERGEANT BLUFF
Mailing Address - State:IA
Mailing Address - Zip Code:51054-0006
Mailing Address - Country:US
Mailing Address - Phone:712-943-1589
Mailing Address - Fax:712-943-1591
Practice Address - Street 1:310 1ST STREET
Practice Address - Street 2:
Practice Address - City:SERGEANT BLUFF
Practice Address - State:IA
Practice Address - Zip Code:51054-0006
Practice Address - Country:US
Practice Address - Phone:712-943-1589
Practice Address - Fax:712-943-1591
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05757111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1107557Medicaid
IA1107557Medicaid
IAU45910Medicare UPIN