Provider Demographics
NPI:1356580732
Name:PETERSON, KELLEY PARKER (DC)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:PARKER
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:NICOLE
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:148 RAY ST STE A
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-6649
Mailing Address - Country:US
Mailing Address - Phone:925-484-0191
Mailing Address - Fax:925-484-0194
Practice Address - Street 1:148 RAY ST STE A
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-6649
Practice Address - Country:US
Practice Address - Phone:925-484-0191
Practice Address - Fax:925-484-0194
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-09
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC31078111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC570AMedicare PIN