Provider Demographics
NPI:1225167109
Name:PETERSON, PHILIP C (DC)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:C
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 1:1924 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-1620
Mailing Address - Country:US
Mailing Address - Phone:805-237-1924
Mailing Address - Fax:805-237-1953
Practice Address - Street 1:1924 SPRING ST
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-1620
Practice Address - Country:US
Practice Address - Phone:805-237-1924
Practice Address - Fax:805-237-1953
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC15845111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T18161Medicare UPIN
CADC15845Medicare PIN