Healthcare Provider Details

I. General information

NPI: 1346234846
Provider Name (Legal Business Name): LYLE D NISSEN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 1ST STREET
SERGEANT BLUFF IA
51054-0006
US

IV. Provider business mailing address

PO BOX 6
SERGEANT BLUFF IA
51054-0006
US

V. Phone/Fax

Practice location:
  • Phone: 712-943-1589
  • Fax: 712-943-1591
Mailing address:
  • Phone: 712-943-1589
  • Fax: 712-943-1591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberA05757
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: