Provider Demographics
NPI:1558631531
Name:PETERSON CHIROPRACTIC
Entity Type:Organization
Organization Name:PETERSON CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC,
Authorized Official - Phone:801-972-1222
Mailing Address - Street 1:1878 W 3600 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3893
Mailing Address - Country:US
Mailing Address - Phone:801-972-1222
Mailing Address - Fax:801-972-2134
Practice Address - Street 1:1878 W 3600 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84119-3893
Practice Address - Country:US
Practice Address - Phone:801-972-1222
Practice Address - Fax:801-972-2134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1737001202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty