Provider Demographics
NPI:1548332083
Name:NICHOLSON, LARRY E (DC)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:E
Last Name:NICHOLSON
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 1:1011 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376
Mailing Address - Country:US
Mailing Address - Phone:209-836-0250
Mailing Address - Fax:209-836-5037
Practice Address - Street 1:1011 PARKER AVE
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376
Practice Address - Country:US
Practice Address - Phone:209-836-0250
Practice Address - Fax:209-836-5037
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17771111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0177710OtherBLUE SHIELD
CADC0177710Medicare ID - Type Unspecified
CADC0177710OtherBLUE SHIELD