Provider Demographics
NPI:1477736171
Name:LUKE H PETERSON DC PA
Entity Type:Organization
Organization Name:LUKE H PETERSON DC PA
Other - Org Name:PRO-ACTIVE FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:H
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-895-6161
Mailing Address - Street 1:1400 LAKE BALDWIN LN
Mailing Address - Street 2:STE. A
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6669
Mailing Address - Country:US
Mailing Address - Phone:407-895-6161
Mailing Address - Fax:407-895-6464
Practice Address - Street 1:1400 LAKE BALDWIN LN
Practice Address - Street 2:STE. A
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6669
Practice Address - Country:US
Practice Address - Phone:407-895-6161
Practice Address - Fax:407-895-6464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8962111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU4576AMedicare PIN
FLV05026Medicare UPIN