Healthcare Provider Details

I. General information

NPI: 1821196205
Provider Name (Legal Business Name): STEPHEN RAY PETTAY DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 BETHEL RD
COLUMBUS OH
43220-1869
US

IV. Provider business mailing address

1875 BETHEL RD
COLUMBUS OH
43220-1869
US

V. Phone/Fax

Practice location:
  • Phone: 614-451-0472
  • Fax: 614-451-0882
Mailing address:
  • Phone: 614-451-0472
  • Fax: 614-451-0882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number976
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: