Provider Demographics
NPI:1134176399
Name:REA, LAIDLER (DC)
Entity type:Individual
Prefix:
First Name:LAIDLER
Middle Name:
Last Name:REA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 S CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-1607
Mailing Address - Country:US
Mailing Address - Phone:650-327-7463
Mailing Address - Fax:
Practice Address - Street 1:480 S CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-1623
Practice Address - Country:US
Practice Address - Phone:650-327-7463
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23356111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0233560Medicaid
CADC23356Medicare ID - Type Unspecified