Basic Information
| Provider Information | |||||||||
| NPI: | 1417915034 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEACE | ||||||||
| FirstName: | DWIGHT | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 STANDIFORD AVE | ||||||||
| Address2: | SUITE F | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953501159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095795628 | ||||||||
| FaxNumber: | 2095795637 | ||||||||
| Practice Location | |||||||||
| Address1: | 134 REGIS ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TURLOCK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953821130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096329965 | ||||||||
| FaxNumber: | 2096329966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT14033 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.