Provider Demographics
NPI:1477730281
Name:BLUMENAUER, PETER G (DC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:G
Last Name:BLUMENAUER
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:PO BOX 12110
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-2110
Mailing Address - Country:US
Mailing Address - Phone:307-734-0222
Mailing Address - Fax:307-734-0222
Practice Address - Street 1:320 EAST BROADWAY
Practice Address - Street 2:SUITE 1C
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-734-0222
Practice Address - Fax:307-734-0222
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY605111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor