Provider Demographics
NPI:1518181833
Name:PETERSON, DREW LELAND (DC)
Entity Type:Individual
Prefix:MR
First Name:DREW
Middle Name:LELAND
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 1:1772 GULFSTREAM AVE
Mailing Address - Street 2:E-1
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34949-3518
Mailing Address - Country:US
Mailing Address - Phone:772-465-9355
Mailing Address - Fax:
Practice Address - Street 1:1010 SOUTH US#1
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34949
Practice Address - Country:US
Practice Address - Phone:772-465-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5374111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner