Healthcare Provider Details

I. General information

NPI: 1700800117
Provider Name (Legal Business Name): IDA MARIE HALLGREN-LUKE D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 RAMBLE CREEK DR
COTATI CA
94931-4321
US

IV. Provider business mailing address

24 RAMBLE CREEK DR
COTATI CA
94931-4321
US

V. Phone/Fax

Practice location:
  • Phone: 707-795-9698
  • Fax: 707-795-9698
Mailing address:
  • Phone: 707-795-9698
  • Fax: 707-795-9698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number10889
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: