Provider Demographics
NPI:1053383802
Name:LAUTERBACH, EDWARD JOSEPH (DC)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOSEPH
Last Name:LAUTERBACH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 TURKEYSAG TRL
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PALMYRA
Mailing Address - State:VA
Mailing Address - Zip Code:22963-2656
Mailing Address - Country:US
Mailing Address - Phone:434-591-0900
Mailing Address - Fax:
Practice Address - Street 1:202 TURKEYSAG TRL
Practice Address - Street 2:SUITE 5
Practice Address - City:PALMYRA
Practice Address - State:VA
Practice Address - Zip Code:22963-2656
Practice Address - Country:US
Practice Address - Phone:434-591-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001713111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA462512OtherANTHEM
VA462512OtherANTHEM