Provider Demographics
NPI:1659390417
Name:PETERSON, BRAD NIEL (DC)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:NIEL
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 1:10358 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-9339
Mailing Address - Country:US
Mailing Address - Phone:801-254-9400
Mailing Address - Fax:801-254-5739
Practice Address - Street 1:10358 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-9339
Practice Address - Country:US
Practice Address - Phone:801-254-9400
Practice Address - Fax:801-254-5739
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT176210-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT612239OtherUNITED HEALTHCARE
UT870503754002Medicaid
UT000056028Medicare ID - Type Unspecified
UT612239OtherUNITED HEALTHCARE
UT238868Medicare UPIN
UT870503754002Medicaid
UT332429Medicare UPIN
UT107001749101Medicare UPIN
UT28813Medicare UPIN