Provider Demographics
NPI:1174605141
Name:PETERSEN, LIDIA THEOLINDA (DC)
Entity type:Individual
Prefix:DR
First Name:LIDIA
Middle Name:THEOLINDA
Last Name:PETERSEN
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 1:11694 SEWARD HWY
Mailing Address - Street 2:STE C
Mailing Address - City:SEWARD
Mailing Address - State:AK
Mailing Address - Zip Code:99664
Mailing Address - Country:US
Mailing Address - Phone:907-224-8680
Mailing Address - Fax:907-224-8910
Practice Address - Street 1:11694 SEWARD HWY
Practice Address - Street 2:STE C
Practice Address - City:SEWARD
Practice Address - State:AK
Practice Address - Zip Code:99664
Practice Address - Country:US
Practice Address - Phone:907-224-8680
Practice Address - Fax:907-224-8910
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK384111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK152168Medicare ID - Type Unspecified