Provider Demographics
NPI:1477763183
Name:PETERSON CHIROPRACTIC CLINIC SC
Entity Type:Organization
Organization Name:PETERSON CHIROPRACTIC CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:CHO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-743-0228
Mailing Address - Street 1:3044 W PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3729
Mailing Address - Country:US
Mailing Address - Phone:773-743-0228
Mailing Address - Fax:773-743-0425
Practice Address - Street 1:3044 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3729
Practice Address - Country:US
Practice Address - Phone:773-743-0228
Practice Address - Fax:773-743-0425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005934111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK16412Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER #
ILT38857Medicare UPIN
IL211416Medicare ID - Type UnspecifiedGROUP PROVIDER #