1033184064 NPI number — CAROLYN RAE PETERS MA, ATC, CSCS

Table of content: CAROLYN RAE PETERS MA, ATC, CSCS (NPI 1033184064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033184064 NPI number — CAROLYN RAE PETERS MA, ATC, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERS
Provider First Name:
CAROLYN
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, ATC, CSCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033184064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5742 HUGHES ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92115-6513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-594-7660
Provider Business Mailing Address Fax Number:
619-594-7654

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5505 CAMPANILE DR.
Provider Second Line Business Practice Location Address:
AAC 1402
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92182-4313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-594-7660
Provider Business Practice Location Address Fax Number:
619-594-7654
Provider Enumeration Date:
02/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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