Provider Demographics
NPI:1750451639
Name:PETTERSON CHIROPRACTIC CLINIC PA
Entity Type:Organization
Organization Name:PETTERSON CHIROPRACTIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:JEREMY
Authorized Official - Last Name:PETTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-480-1128
Mailing Address - Street 1:825 BAHLS DRIVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033
Mailing Address - Country:US
Mailing Address - Phone:651-480-1128
Mailing Address - Fax:651-438-3929
Practice Address - Street 1:825 BAHLS DRIVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033
Practice Address - Country:US
Practice Address - Phone:651-480-1128
Practice Address - Fax:651-438-3929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3748111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03874OtherMEDICARE GROUP #
MN10G0179OtherHEALTH PARTNERS
MN198G8PEOtherBLUE CROSS BLUE SHIELD #
U78007Medicare UPIN