Provider Demographics
NPI:1083372767
Name:100 CHIRO PETERSON WALFOORT, LLC
Entity Type:Organization
Organization Name:100 CHIRO PETERSON WALFOORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRANCHISEE
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-252-8184
Mailing Address - Street 1:1921 PRESTON RD STE B2008
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5124
Mailing Address - Country:US
Mailing Address - Phone:719-252-8184
Mailing Address - Fax:
Practice Address - Street 1:1921 PRESTON RD STE B2008
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5124
Practice Address - Country:US
Practice Address - Phone:719-252-8184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty