Provider Demographics
NPI:1790901056
Name:CARLSON, ROY PETER (CH)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:PETER
Last Name:CARLSON
Suffix:
Gender:M
Credentials:CH
Other - Prefix:
Other - First Name:R
Other - Middle Name:PETER
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CH
Mailing Address - Street 1:531 S GROVE ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-4820
Mailing Address - Country:US
Mailing Address - Phone:352-360-3601
Mailing Address - Fax:
Practice Address - Street 1:1400 W OAK ST STE B
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4000
Practice Address - Country:US
Practice Address - Phone:407-944-9355
Practice Address - Fax:407-933-1237
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3219111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT55805Medicare UPIN