MEDICARE: DR. PETER THIBODEAU D.C.

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	111NN0400X	Neurology Chiropractor	DC10123	CA

General Provider Information

NPI Number	:	1114952629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER THIBODEAU D.C.

Provider Business Mailing Address
First Line	:	3121 PARK AVE
Second Line	:	B
City	:	SOQUEL
State	:	CA
Zip	:	95073-2920
Country	:	US
Telephone Number	:	831-462-2727
Fax Number	:

Provider Business Practice Location Address
First Line	:	3121 PARK AVE
Second Line	:	B
City	:	SOQUEL
State	:	CA
Zip	:	95073-2920
Country	:	US
Telephone Number	:	831-462-2727
Fax Number	:

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/08/2007

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