Healthcare Provider Details

I. General information

NPI: 1467438283
Provider Name (Legal Business Name): CRAIG SCOTT PETERSEN RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 STOCKTON BLVD G 112
SACRAMENTO CA
95817
US

IV. Provider business mailing address

3516 ROCKY RIDGE WAY
EL DORADO HILLS CA
95762-4430
US

V. Phone/Fax

Practice location:
  • Phone: 916-703-3114
  • Fax:
Mailing address:
  • Phone: 916-933-1048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: