Provider Demographics
NPI:1891853453
Name:PETERSEN, TIMOTHY DEE (DC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DEE
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 1:2351 SUNSET BLVD
Mailing Address - Street 2:STE 120
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765
Mailing Address - Country:US
Mailing Address - Phone:916-624-2500
Mailing Address - Fax:916-624-4196
Practice Address - Street 1:2351 SUNSET BLVD
Practice Address - Street 2:STE 120
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765
Practice Address - Country:US
Practice Address - Phone:916-624-2500
Practice Address - Fax:916-624-4196
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21088111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATP1003401OtherHSHP
CADC0210880 5422OtherBLUE CROSS BLUE SHIELD
CADC0210880 5422OtherBLUE CROSS BLUE SHIELD