Provider Demographics
NPI:1619162047
Name:THEODORE, PEYTON (LAC)
Entity Type:Individual
Prefix:
First Name:PEYTON
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 FREDA LN
Mailing Address - Street 2:
Mailing Address - City:CARDIFF BY THE SEA
Mailing Address - State:CA
Mailing Address - Zip Code:92007-1416
Mailing Address - Country:US
Mailing Address - Phone:760-681-7507
Mailing Address - Fax:
Practice Address - Street 1:243 N HIGHWAY 101
Practice Address - Street 2:SUITE 13
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-1180
Practice Address - Country:US
Practice Address - Phone:760-681-7507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 13907171100000X
PAAK000884171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist