Provider Demographics
NPI:1770874364
Name:DENBLAKER, LAURA TRACEY (DC)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:TRACEY
Last Name:DENBLAKER
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 1:1366 W 7TH ST
Mailing Address - Street 2:SUITE 4-B
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3500
Mailing Address - Country:US
Mailing Address - Phone:310-547-2197
Mailing Address - Fax:310-547-9532
Practice Address - Street 1:1366 W 7TH ST
Practice Address - Street 2:SUITE 4-B
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3500
Practice Address - Country:US
Practice Address - Phone:310-547-2197
Practice Address - Fax:310-547-9532
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21667111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC21667OtherCHIRO