Provider Demographics
NPI:1972888006
Name:PHILIP C. PETERSON, A PROFESSIONAL CHIROPRACTIC CORPORATION
Entity type:Organization
Organization Name:PHILIP C. PETERSON, A PROFESSIONAL CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:805-237-1924
Mailing Address - Street 1:1545 PARK ST
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-2161
Mailing Address - Country:US
Mailing Address - Phone:805-237-1924
Mailing Address - Fax:805-237-1953
Practice Address - Street 1:1545 PARK ST
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-2161
Practice Address - Country:US
Practice Address - Phone:805-237-1924
Practice Address - Fax:805-237-1953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC15845111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT18161Medicare UPIN
CADC15845Medicare PIN