Provider Demographics
NPI:1063444776
Name:PETERSON, GLEN ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:ALLEN
Last Name:PETERSON
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 1:817 N SMITHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-7717
Mailing Address - Country:US
Mailing Address - Phone:919-217-8188
Mailing Address - Fax:919-217-8189
Practice Address - Street 1:817 N SMITHFIELD RD
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-7717
Practice Address - Country:US
Practice Address - Phone:919-217-8188
Practice Address - Fax:919-217-8189
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3728111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5907457Medicaid