Provider Demographics
NPI:1790881670
Name:LUNDBAEK, JESPER (DC)
Entity Type:Individual
Prefix:DR
First Name:JESPER
Middle Name:
Last Name:LUNDBAEK
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 1:591 REDWOOD HIGHWAY
Mailing Address - Street 2:SUITE 2300 MILL VALLEY FAMILY CHIROPRACTIC
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941
Mailing Address - Country:US
Mailing Address - Phone:415-389-9000
Mailing Address - Fax:415-389-7912
Practice Address - Street 1:591 REDWOOD HIGHWAY
Practice Address - Street 2:SUITE 2300 MILL VALLEY FAMILY CHIROPRACTIC
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941
Practice Address - Country:US
Practice Address - Phone:415-389-9000
Practice Address - Fax:415-389-7912
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA22400111N00000X
HIHI664111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0224000Medicare UPIN