Provider Demographics
NPI:1235232505
Name:PETERSON, JAMES EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:EDWARD
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 1:2615 S MILLER ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-1775
Mailing Address - Country:US
Mailing Address - Phone:805-938-7480
Mailing Address - Fax:805-938-7492
Practice Address - Street 1:2615 S MILLER ST
Practice Address - Street 2:SUITE 108
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-1775
Practice Address - Country:US
Practice Address - Phone:805-938-7480
Practice Address - Fax:805-938-7492
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 12789111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT 17447Medicare UPIN