Provider Demographics
NPI:1760697262
Name:PETERSEN, CRAIG M (DC)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:M
Last Name:PETERSEN
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 1:31734 RANCHO VIEJO RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-2782
Mailing Address - Country:US
Mailing Address - Phone:949-388-1432
Mailing Address - Fax:949-388-1434
Practice Address - Street 1:31734 RANCHO VIEJO RD
Practice Address - Street 2:SUITE C
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-2782
Practice Address - Country:US
Practice Address - Phone:949-388-1432
Practice Address - Fax:949-388-1434
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25168111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC25168Medicare ID - Type Unspecified