Provider Demographics
NPI:1043245350
Name:PETERSON, LAURA LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24988 BLUE RAVINE RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-5284
Mailing Address - Country:US
Mailing Address - Phone:916-355-0440
Mailing Address - Fax:916-355-0441
Practice Address - Street 1:24988 BLUE RAVINE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-5284
Practice Address - Country:US
Practice Address - Phone:916-355-0440
Practice Address - Fax:916-355-0441
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26119111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ26751ZMedicare UPIN
CADC0261190Medicare ID - Type Unspecified