Provider Demographics
NPI:1912375254
Name:PETERS, ERIC JOSEPH SR
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:JOSEPH
Last Name:PETERS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SMITH RANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903
Mailing Address - Country:US
Mailing Address - Phone:415-492-0818
Mailing Address - Fax:415-492-0834
Practice Address - Street 1:629 WILSON AVE
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-3823
Practice Address - Country:US
Practice Address - Phone:415-492-0818
Practice Address - Fax:415-492-0834
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAP0809051024324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAN5526983Medicaid