Provider Demographics
NPI:1134149073
Name:PETERS, MARCO ANTONIO (DC)
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:ANTONIO
Last Name:PETERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 SOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-1109
Mailing Address - Country:US
Mailing Address - Phone:704-521-1389
Mailing Address - Fax:704-527-3687
Practice Address - Street 1:2727 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-1109
Practice Address - Country:US
Practice Address - Phone:704-521-1389
Practice Address - Fax:704-527-3687
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2998111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC085G9OtherBCBS
NC89085G9Medicaid
NC89085G9Medicaid