Healthcare Provider Details

I. General information

NPI: 1538177530
Provider Name (Legal Business Name): BRUCE DOUGLAS PETERSON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18080 SAN RAMON VALLEY BLVD SUITE 102
SAN RAMON CA
94583-4434
US

IV. Provider business mailing address

18080 SAN RAMON VALLEY BLVD SUITE 102
SAN RAMON CA
94583-4434
US

V. Phone/Fax

Practice location:
  • Phone: 925-830-1011
  • Fax: 925-830-1022
Mailing address:
  • Phone: 925-830-1011
  • Fax: 925-830-1022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number14467
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: