Provider Demographics
NPI:1417915034
Name:PEACE, DWIGHT ALAN (PT)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:ALAN
Last Name:PEACE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:220 STANDIFORD AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1159
Mailing Address - Country:US
Mailing Address - Phone:209-579-5628
Mailing Address - Fax:209-579-5637
Practice Address - Street 1:134 REGIS ST
Practice Address - Street 2:SUITE A
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-1130
Practice Address - Country:US
Practice Address - Phone:209-632-9965
Practice Address - Fax:209-632-9966
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14033225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ27909ZMedicare ID - Type Unspecified