Healthcare Provider Details

I. General information

NPI: 1114070406
Provider Name (Legal Business Name): CORRIE JOESPH PELTIER LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31065 FOREST BLVD.
STACY MN
55079
US

IV. Provider business mailing address

PO BOX 30
STACY MN
55079-0030
US

V. Phone/Fax

Practice location:
  • Phone: 650-408-7121
  • Fax:
Mailing address:
  • Phone: 651-408-7121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1032392-1-CDT
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: