Provider Demographics
NPI:1700958972
Name:DWIGHT A. PEACE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:DWIGHT A. PEACE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:PEACE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:209-632-9965
Mailing Address - Street 1:220 STANDIFORD AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1159
Mailing Address - Country:US
Mailing Address - Phone:209-579-5628
Mailing Address - Fax:209-579-5637
Practice Address - Street 1:134 REGIS ST
Practice Address - Street 2:SUITE A
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-1130
Practice Address - Country:US
Practice Address - Phone:209-632-9965
Practice Address - Fax:209-632-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14033225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT140330OtherBLUE SHEILD
CA0PT140330OtherBLUE SHEILD