Provider Demographics
NPI:1598864282
Name:PETERSON, NICKALOS LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:NICKALOS
Middle Name:LEE
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 1:31 BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-4533
Mailing Address - Country:US
Mailing Address - Phone:203-438-9609
Mailing Address - Fax:203-438-7141
Practice Address - Street 1:31 BAILEY AVE
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-4533
Practice Address - Country:US
Practice Address - Phone:203-438-9609
Practice Address - Fax:203-438-7141
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT180111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP405105OtherOXFORD PROVIDER ID NUMBER
CT4380815OtherAETNA PPO ID NUMBER
CT050000180CT01OtherANTHEM BC/BS ID PROVIDER
CTLANDMARK /HEALTH NETOtherCT00180 PROVIDER ID#
CT9323280003OtherCIGNA PROVIDER ID NUMBER
CT0114667OtherAETNA HMO ID NUMBER