Provider Demographics
NPI:1902842123
Name:PETERSON, ERICK ALLEN (DC, CCSP)
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:ALLEN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4148
Mailing Address - Country:US
Mailing Address - Phone:919-286-7202
Mailing Address - Fax:919-287-2302
Practice Address - Street 1:816 BROAD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4148
Practice Address - Country:US
Practice Address - Phone:919-286-7202
Practice Address - Fax:919-287-2302
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2865111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89085AHMedicaid
NC085AHOtherBLUE CROSS PROVIDER ID
NC2454147AMedicare ID - Type Unspecified
NC89085AHMedicaid