Provider Demographics
NPI:1275685281
Name:PETKER, LAWRENCE RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:RICHARD
Last Name:PETKER
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 1:50 S PERROTT DR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-6227
Mailing Address - Country:US
Mailing Address - Phone:386-615-0801
Mailing Address - Fax:386-672-4811
Practice Address - Street 1:50 S PERROTT DR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-6227
Practice Address - Country:US
Practice Address - Phone:386-615-0801
Practice Address - Fax:386-672-4811
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3821111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor