Provider Demographics
NPI:1023103181
Name:PREBLE, LAURENCE DANIEL (DC)
Entity type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:DANIEL
Last Name:PREBLE
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 1:102 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-1428
Mailing Address - Country:US
Mailing Address - Phone:502-222-7611
Mailing Address - Fax:
Practice Address - Street 1:102 W MADISON ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-1428
Practice Address - Country:US
Practice Address - Phone:502-222-7611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3668-R111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85001543Medicaid
KYT54208Medicare UPIN
KY6000601Medicare ID - Type UnspecifiedLDP AT LA GRANGE OFFICE
KY6000602Medicare ID - Type UnspecifiedLDP AT OUTER LOOP OFFICE