Provider Demographics
NPI:1508039777
Name:PETERSON, MATTHEW S (DC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
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 656
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541-0656
Mailing Address - Country:US
Mailing Address - Phone:360-482-5155
Mailing Address - Fax:360-482-4155
Practice Address - Street 1:103 N. 1ST STREET
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541-0656
Practice Address - Country:US
Practice Address - Phone:360-482-5155
Practice Address - Fax:360-482-4155
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003029111N00000X
UT295378-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2020535Medicaid
WAG8872157Medicare PIN
WA2020535Medicaid