Healthcare Provider Details

I. General information

NPI: 1053383802
Provider Name (Legal Business Name): EDWARD JOSEPH LAUTERBACH D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 TURKEYSAG TRL SUITE 5
PALMYRA VA
22963-2656
US

IV. Provider business mailing address

202 TURKEYSAG TRL SUITE 5
PALMYRA VA
22963-2656
US

V. Phone/Fax

Practice location:
  • Phone: 434-591-0900
  • Fax:
Mailing address:
  • Phone: 434-591-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104001713
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: