=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427302355
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUZANNE PETERSEN CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2012
-----------------------------------------------------
Last Update Date | 10/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2351 SUNSET BLVD STE 120
-----------------------------------------------------
City | ROCKLIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95765-4338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-624-2500
-----------------------------------------------------
Fax | 916-624-4196
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2351 SUNSET BLVD STE 120
-----------------------------------------------------
City | ROCKLIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95765-4338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 916-624-4196
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | DR. TIMOTHY DEE PETERSEN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 916-624-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 21088
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------