Provider Demographics
NPI:1417139965
Name:PETERSON, RICARDO ALBIN (LAC)
Entity Type:Individual
Prefix:MR
First Name:RICARDO
Middle Name:ALBIN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2645 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-6506
Mailing Address - Country:US
Mailing Address - Phone:619-239-7516
Mailing Address - Fax:619-239-7606
Practice Address - Street 1:2645 1ST AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6506
Practice Address - Country:US
Practice Address - Phone:619-239-7516
Practice Address - Fax:619-239-7606
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12030171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist