Provider Demographics
NPI:1881726040
Name:LADD, PETER LEE (DC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:LEE
Last Name:LADD
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 1:1089 ROBERT ST S
Mailing Address - Street 2:
Mailing Address - City:WEST SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-1456
Mailing Address - Country:US
Mailing Address - Phone:651-457-5435
Mailing Address - Fax:651-457-8091
Practice Address - Street 1:1089 ROBERT ST S
Practice Address - Street 2:
Practice Address - City:WEST SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-1456
Practice Address - Country:US
Practice Address - Phone:651-457-5435
Practice Address - Fax:651-457-8091
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN003388111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN138024900Medicaid
MN003388OtherCHIROPRACTIC LICENSCE
MN138024900Medicaid
MN350003422Medicare ID - Type UnspecifiedMEDICARE NUMBER