Provider Demographics
NPI:1912180696
Name:PETER CROCKER DC INC.
Entity Type:Organization
Organization Name:PETER CROCKER DC INC.
Other - Org Name:TATUM CROSSING CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:D
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-513-8900
Mailing Address - Street 1:29834 N CAVE CREEK RD
Mailing Address - Street 2:SUITE B110
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-5836
Mailing Address - Country:US
Mailing Address - Phone:480-513-8900
Mailing Address - Fax:480-513-9395
Practice Address - Street 1:29834 N CAVE CREEK RD
Practice Address - Street 2:SUITE B110
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331-5836
Practice Address - Country:US
Practice Address - Phone:480-513-8900
Practice Address - Fax:480-513-9395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5854111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ73324OtherMEDICARE GROUP