Provider Demographics
NPI:1114581394
Name:PETERSON, DERRIK BRIAN (DC)
Entity Type:Individual
Prefix:DR
First Name:DERRIK
Middle Name:BRIAN
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 1:15911 POMONA RINCON RD
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-5566
Mailing Address - Country:US
Mailing Address - Phone:909-334-2230
Mailing Address - Fax:
Practice Address - Street 1:15911 POMONA RINCON RD
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5566
Practice Address - Country:US
Practice Address - Phone:909-334-2230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34377111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty