Provider Demographics
NPI:1053672246
Name:FOO, PETRA (LAC)
Entity Type:Individual
Prefix:MRS
First Name:PETRA
Middle Name:
Last Name:FOO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1641 N MILWAUKEE AVE
Mailing Address - Street 2:#9
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-1350
Mailing Address - Country:US
Mailing Address - Phone:847-971-9393
Mailing Address - Fax:847-929-9568
Practice Address - Street 1:1641 N MILWAUKEE AVE
Practice Address - Street 2:#9
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-1350
Practice Address - Country:US
Practice Address - Phone:847-971-9393
Practice Address - Fax:847-929-9568
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000516171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1700185741OtherNPI FOR GROUP HEALTHY BODY HEALTHY MIND, INC.