Provider Demographics
NPI:1073566519
Name:PETRIE CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:PETRIE CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETRIE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-288-3614
Mailing Address - Street 1:315 S PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-2956
Mailing Address - Country:US
Mailing Address - Phone:815-288-3614
Mailing Address - Fax:815-285-3525
Practice Address - Street 1:315 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-2956
Practice Address - Country:US
Practice Address - Phone:815-288-3614
Practice Address - Fax:815-285-3525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038004367111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038004367Medicaid
IL5282006OtherBLUE CROSS/ BLUE SHIELD
IL038004367Medicaid