Provider Demographics
NPI:1033683677
Name:PETERSON, MARTINA (DC)
Entity Type:Individual
Prefix:DR
First Name:MARTINA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
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:PO BOX 493
Mailing Address - Street 2:
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727-0493
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:306 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST JORDAN
Practice Address - State:MI
Practice Address - Zip Code:49727-5127
Practice Address - Country:US
Practice Address - Phone:231-675-0733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010699111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor