Healthcare Provider Details

I. General information

NPI: 1154824274
Provider Name (Legal Business Name): CHARLOTTE PROACTIVE PETERS DC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 03/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11220 GOLF LINKS DRIVE
CHARLOTTE NC
28277
US

IV. Provider business mailing address

PO BOX 686
CHANHASSEN MN
55317-0686
US

V. Phone/Fax

Practice location:
  • Phone: 704-901-7192
  • Fax:
Mailing address:
  • Phone: 952-229-7464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3772
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP15776
License Number StateNC

VIII. Authorized Official

Name: DR. STEWART PETERS
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 704-901-7192