Provider Demographics
NPI:1376813378
Name:PETERSON HEALTH CLINIC LLC
Entity Type:Organization
Organization Name:PETERSON HEALTH CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:618-589-3911
Mailing Address - Street 1:815 LINCOLN HIGHWAY
Mailing Address - Street 2:SUITE 109
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208
Mailing Address - Country:US
Mailing Address - Phone:618-589-3911
Mailing Address - Fax:618-589-3912
Practice Address - Street 1:815 LINCOLN HIGHWAY
Practice Address - Street 2:SUITE 109
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208
Practice Address - Country:US
Practice Address - Phone:618-589-3911
Practice Address - Fax:618-589-3912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL248.000537111N00000X
IL038.012069111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty