Provider Demographics
NPI:1275610222
Name:COON VALLEY CHIROPRACTIC S.C.
Entity Type:Organization
Organization Name:COON VALLEY CHIROPRACTIC S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYPAT
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-452-2525
Mailing Address - Street 1:113 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:COON VALLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54623-8039
Mailing Address - Country:US
Mailing Address - Phone:608-452-2525
Mailing Address - Fax:608-452-2526
Practice Address - Street 1:113 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:COON VALLEY
Practice Address - State:WI
Practice Address - Zip Code:54623-8039
Practice Address - Country:US
Practice Address - Phone:608-452-2525
Practice Address - Fax:608-452-2526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3133-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty