MEDICARE: CORRIE JOESPH PELTIER LADC

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	324500000X	Substance Abuse Rehabilitation Facility	1032392-1-CDT	MN

General Provider Information

NPI Number	:	1114070406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORRIE JOESPH PELTIER LADC

Provider Business Mailing Address
First Line	:	PO BOX 30
Second Line	:
City	:	STACY
State	:	MN
Zip	:	55079-0030
Country	:	US
Telephone Number	:	651-408-7121
Fax Number	:

Provider Business Practice Location Address
First Line	:	31065 FOREST BLVD.
Second Line	:
City	:	STACY
State	:	MN
Zip	:	55079
Country	:	US
Telephone Number	:	650-408-7121
Fax Number	:

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

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	07/08/2007

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