Provider Demographics
NPI:1083687636
Name:CHARLES J PETERSON DC PC
Entity Type:Organization
Organization Name:CHARLES J PETERSON DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:712-246-4798
Mailing Address - Street 1:1203 W SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601
Mailing Address - Country:US
Mailing Address - Phone:712-246-4798
Mailing Address - Fax:712-246-5613
Practice Address - Street 1:1203 W SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601
Practice Address - Country:US
Practice Address - Phone:712-246-4798
Practice Address - Fax:712-246-5613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04065111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA01527OtherWELLMARK
IA0015271Medicaid
IA0015271Medicaid
TOO179Medicare UPIN