Provider Demographics
NPI:1174571012
Name:HANSSEN, GAYLORD HAROLD (DC FIACA)
Entity type:Individual
Prefix:MR
First Name:GAYLORD
Middle Name:HAROLD
Last Name:HANSSEN
Suffix:
Gender:M
Credentials:DC FIACA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-4529
Mailing Address - Country:US
Mailing Address - Phone:308-382-7470
Mailing Address - Fax:308-382-9398
Practice Address - Street 1:706 W 4TH ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-4529
Practice Address - Country:US
Practice Address - Phone:308-382-7470
Practice Address - Fax:308-382-9398
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE894111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47076250613Medicaid
NE47076250613Medicaid
NE274990Medicare ID - Type Unspecified