Provider Demographics
NPI:1164646741
Name:PETERSON, KENNETH R (DC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:PETERSON
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 1:62 FORT HILL RD
Mailing Address - Street 2:STE B
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4398
Mailing Address - Country:US
Mailing Address - Phone:860-440-6754
Mailing Address - Fax:860-440-6757
Practice Address - Street 1:62 FORT HILL RD STE B
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4398
Practice Address - Country:US
Practice Address - Phone:860-440-6754
Practice Address - Fax:860-495-0043
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001702111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor