Provider Demographics
NPI:1548653819
Name:JOHN S PETERSON DC A CHIROPRACTIC CORPORATION
Entity type:Organization
Organization Name:JOHN S PETERSON DC A CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:714-776-7111
Mailing Address - Street 1:1309 S EUCLID ST
Mailing Address - Street 2:STE A
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-2078
Mailing Address - Country:US
Mailing Address - Phone:714-776-7111
Mailing Address - Fax:714-776-9693
Practice Address - Street 1:1309 S EUCLID ST
Practice Address - Street 2:STE A
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-2078
Practice Address - Country:US
Practice Address - Phone:714-776-7111
Practice Address - Fax:714-776-9693
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN S PETERSON DC A CHIROPRACTIC CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17788111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT18611Medicare UPIN
CADC17788Medicare PIN