Provider Demographics
NPI:1629035167
Name:PETERSON, JULIE (DC)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7504 86TH STREET SW, SUITE 150
Mailing Address - Street 2:VITAL FAMILY CHIROPRACTIC
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498
Mailing Address - Country:US
Mailing Address - Phone:843-200-9400
Mailing Address - Fax:888-411-8529
Practice Address - Street 1:7504 86TH STREET SW, SUITE 150
Practice Address - Street 2:VITAL FAMILY CHIROPRACTIC
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98498
Practice Address - Country:US
Practice Address - Phone:843-200-9400
Practice Address - Fax:888-411-8529
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2166111N00000X
WACH60191318111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2167Medicaid
SCU7089OtherUPIN
SCCH2167Medicaid
SCU708910281Medicare ID - Type Unspecified