=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609835289
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY PECK DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2006
-----------------------------------------------------
Last Update Date | 11/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2934 POINT MALLARD PKWY SE STE B2
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35603-5710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-584-9554
-----------------------------------------------------
Fax | 256-253-5502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14608 WATERVIEW LN
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35613-1606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-977-5419
-----------------------------------------------------
Fax | 256-253-5502
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 6062
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038007895
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1488
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------