Provider Demographics
NPI:1639791932
Name:PETERSON WELLNESS CLINIC P.A.
Entity Type:Organization
Organization Name:PETERSON WELLNESS CLINIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:LELAND
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-583-5839
Mailing Address - Street 1:194 PROGRESS WAY
Mailing Address - Street 2:
Mailing Address - City:SPICER
Mailing Address - State:MN
Mailing Address - Zip Code:56288-5000
Mailing Address - Country:US
Mailing Address - Phone:320-583-5839
Mailing Address - Fax:
Practice Address - Street 1:194 PROGRESS WAY
Practice Address - Street 2:
Practice Address - City:SPICER
Practice Address - State:MN
Practice Address - Zip Code:56288-5000
Practice Address - Country:US
Practice Address - Phone:320-583-5839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty