Provider Demographics
NPI:1497765747
Name:PERETTI, MICHAEL FRED (DC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:FRED
Last Name:PERETTI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:FRED
Other - Last Name:PERETTI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:7000 SOUTH AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-3644
Mailing Address - Country:US
Mailing Address - Phone:330-629-8834
Mailing Address - Fax:330-629-9362
Practice Address - Street 1:7000 SOUTH AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-3644
Practice Address - Country:US
Practice Address - Phone:330-629-8834
Practice Address - Fax:330-629-9362
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1754111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0926289Medicaid
OHU42020Medicare UPIN
OHPE0738512Medicare PIN