Provider Demographics
NPI:1730363003
Name:PETTY, PAUL CEIF (DC)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:CEIF
Last Name:PETTY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 BAKER ST STE G
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3752
Mailing Address - Country:US
Mailing Address - Phone:714-435-1996
Mailing Address - Fax:
Practice Address - Street 1:1530 BAKER ST STE G
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3752
Practice Address - Country:US
Practice Address - Phone:714-435-1996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17260111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor