Provider Demographics
NPI:1851526339
Name:PETERSEN CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:PETERSEN CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-275-8727
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:BELFAIR
Mailing Address - State:WA
Mailing Address - Zip Code:98528-0370
Mailing Address - Country:US
Mailing Address - Phone:360-275-8727
Mailing Address - Fax:360-275-9695
Practice Address - Street 1:151 NE STATE ROUTE 300
Practice Address - Street 2:
Practice Address - City:BELFAIR
Practice Address - State:WA
Practice Address - Zip Code:98528-9615
Practice Address - Country:US
Practice Address - Phone:360-275-8727
Practice Address - Fax:360-275-9695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2694111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA44709OtherLABOR AND INDUSTRIES
WA2015212Medicaid
WA2015212Medicaid