Provider Demographics
NPI:1386779577
Name:PETKER, AUGUST M (DC)
Entity type:Individual
Prefix:DR
First Name:AUGUST
Middle Name:M
Last Name:PETKER
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 1:220 MASON AVE.
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:FL
Mailing Address - Zip Code:32117
Mailing Address - Country:US
Mailing Address - Phone:386-258-7474
Mailing Address - Fax:386-248-1466
Practice Address - Street 1:220 MASON AVE
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-5039
Practice Address - Country:US
Practice Address - Phone:386-258-7474
Practice Address - Fax:386-248-1466
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3034111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88314Medicare ID - Type Unspecified