Healthcare Provider Details

I. General information

NPI: 1932230950
Provider Name (Legal Business Name): ALFRED PETER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11679 NE GLISAN ST
PORTLAND OR
97220-2264
US

IV. Provider business mailing address

12303 SE HUBBARD RD
CLACKAMAS OR
97015-8218
US

V. Phone/Fax

Practice location:
  • Phone: 503-258-9592
  • Fax:
Mailing address:
  • Phone: 503-698-9631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number1278
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: