Provider Demographics
NPI:1144757774
Name:PETRIS, PHILLIP (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:PETRIS
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 1:551 LAKEHURST RD FL 1
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-8044
Mailing Address - Country:US
Mailing Address - Phone:732-678-6785
Mailing Address - Fax:
Practice Address - Street 1:551 LAKEHURST RD FL 1
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755
Practice Address - Country:US
Practice Address - Phone:732-678-6785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00547900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor