Provider Demographics
NPI:1851412241
Name:PETERSON, DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
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 1:17331 PENN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95946-9340
Mailing Address - Country:US
Mailing Address - Phone:530-615-4083
Mailing Address - Fax:530-532-5085
Practice Address - Street 1:17331 PENN VALLEY DR
Practice Address - Street 2:
Practice Address - City:PENN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95946-9340
Practice Address - Country:US
Practice Address - Phone:530-615-4083
Practice Address - Fax:530-532-5085
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO6257111N00000X
CA28995111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
31678Medicare UPIN