Provider Demographics
NPI:1790772028
Name:STEPHENS, PETER WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:WILLIAM
Last Name:STEPHENS
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 1:375 SW 32ND ST
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974-5919
Mailing Address - Country:US
Mailing Address - Phone:863-763-0880
Mailing Address - Fax:863-763-3077
Practice Address - Street 1:375 SW 32ND ST
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34974-5919
Practice Address - Country:US
Practice Address - Phone:863-763-0880
Practice Address - Fax:863-763-3077
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0003189111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T55800Medicare UPIN
88368Medicare ID - Type Unspecified