Provider Demographics
NPI:1639104987
Name:PETERSON, RICHARD L (DC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:L
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 1:2185 LIBERTY ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-8353
Mailing Address - Country:US
Mailing Address - Phone:503-371-4055
Mailing Address - Fax:503-371-4885
Practice Address - Street 1:2185 LIBERTY ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-8353
Practice Address - Country:US
Practice Address - Phone:503-371-4055
Practice Address - Fax:503-371-4885
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27 1346111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000QGBLROtherPTAN