Provider Demographics
NPI:1790717817
Name:PETERSON, BRADLEY R (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:R
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 1:1878 W 3600 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3893
Mailing Address - Country:US
Mailing Address - Phone:801-972-1222
Mailing Address - Fax:801-972-2134
Practice Address - Street 1:1878 W 3600 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-3893
Practice Address - Country:US
Practice Address - Phone:801-972-1222
Practice Address - Fax:801-972-2134
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT173700-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT89143Medicare UPIN