Provider Demographics
NPI:1003986886
Name:PETTERSON, CHAD JEREMY (DC)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:JEREMY
Last Name:PETTERSON
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 1:825 BAHLS DRIVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033
Mailing Address - Country:US
Mailing Address - Phone:651-480-1128
Mailing Address - Fax:651-438-3929
Practice Address - Street 1:825 BAHLS DRIVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033
Practice Address - Country:US
Practice Address - Phone:651-480-1128
Practice Address - Fax:651-438-3929
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3748111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN198G8PEOtherBLUE CROSS BLUE SHIELD #
MNCO3874OtherMEDICARE GROUP #
MN106179OtherHEALTH PARTNERS #
MN198G8PEOtherBLUE CROSS BLUE SHIELD #