Provider Demographics
NPI:1699093708
Name:LOFGREN, LEE MICHAEL (DC)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:MICHAEL
Last Name:LOFGREN
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 1:160 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3116
Mailing Address - Country:US
Mailing Address - Phone:307-332-6148
Mailing Address - Fax:307-332-5157
Practice Address - Street 1:160 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3116
Practice Address - Country:US
Practice Address - Phone:307-332-6148
Practice Address - Fax:307-332-5157
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY490111N00000X
MT557111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW307327OtherMEDICARE PROVIDER #
WYW307327OtherMEDICARE PROVIDER #
T81766Medicare UPIN