Provider Demographics
NPI:1225112311
Name:PETERSON, RODNEY W (DOCTOR OF CHIROPRACT)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:W
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DOCTOR OF CHIROPRACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 S UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6030
Mailing Address - Country:US
Mailing Address - Phone:701-237-0614
Mailing Address - Fax:701-237-0615
Practice Address - Street 1:2800 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6030
Practice Address - Country:US
Practice Address - Phone:701-237-0614
Practice Address - Fax:701-237-0615
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND515111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND016742Medicaid
MN502228200Medicaid
ND016742Medicaid
NDN10764Medicare PIN