Provider Demographics
NPI:1245855816
Name:PELTZ, ERIC JOHN
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:JOHN
Last Name:PELTZ
Suffix:
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 1:898 322ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-5810
Mailing Address - Country:US
Mailing Address - Phone:763-234-3308
Mailing Address - Fax:
Practice Address - Street 1:898 322ND AVE NE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-5810
Practice Address - Country:US
Practice Address - Phone:763-234-3308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1103722372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1103722OtherMN ADULT FOSTER CARE LICENSE
MN1104550OtherMN DHS 245D LICENSE - ADULT FOSTER CARE LICENSE