Provider Demographics
NPI:1073648168
Name:PEABODY, ERICA MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:ERICA
Middle Name:MARIE
Last Name:PEABODY
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 1:114 W CAROLINE ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3802
Mailing Address - Country:US
Mailing Address - Phone:810-629-6023
Mailing Address - Fax:810-629-6024
Practice Address - Street 1:114 W CAROLINE ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3802
Practice Address - Country:US
Practice Address - Phone:810-629-6023
Practice Address - Fax:810-629-6024
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008978111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P11840Medicare ID - Type Unspecified