MEDICARE: MR. RICARDO ALBIN PETERSON L.AC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	12030	CA

General Provider Information

NPI Number	:	1417139965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICARDO ALBIN PETERSON L.AC.

Provider Business Mailing Address
First Line	:	2645 1ST AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-6506
Country	:	US
Telephone Number	:	619-239-7516
Fax Number	:	619-239-7606

Provider Business Practice Location Address
First Line	:	2645 1ST AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-6506
Country	:	US
Telephone Number	:	619-239-7516
Fax Number	:	619-239-7606

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2007
Last Update Date	:	11/27/2007

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