Provider Demographics
NPI:1437209418
Name:PETERSON, GLEN R (DC)
Entity Type:Individual
Prefix:DR
First Name:GLEN
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:PO BOX 1204
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-3204
Mailing Address - Country:US
Mailing Address - Phone:815-223-4201
Mailing Address - Fax:815-223-4210
Practice Address - Street 1:501 1ST ST
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-2416
Practice Address - Country:US
Practice Address - Phone:815-223-4201
Practice Address - Fax:814-223-4210
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008373111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician