Provider Demographics
NPI:1326379009
Name:PEDERSEN CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:PEDERSEN CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:859-858-0200
Mailing Address - Street 1:405 N LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WILMORE
Mailing Address - State:KY
Mailing Address - Zip Code:40390-1195
Mailing Address - Country:US
Mailing Address - Phone:859-858-0200
Mailing Address - Fax:859-858-0092
Practice Address - Street 1:405 N LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:WILMORE
Practice Address - State:KY
Practice Address - Zip Code:40390-1195
Practice Address - Country:US
Practice Address - Phone:859-858-0200
Practice Address - Fax:859-858-0092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5217111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty