Provider Demographics
NPI:1679832695
Name:PETERS, BRUCE EDWARD (LAC)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:EDWARD
Last Name:PETERS
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 1:25 CHATTANOOGA ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-3024
Mailing Address - Country:US
Mailing Address - Phone:415-203-4407
Mailing Address - Fax:
Practice Address - Street 1:25 CHATTANOOGA ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-3024
Practice Address - Country:US
Practice Address - Phone:415-203-4407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14724171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist