Provider Demographics
NPI:1891977930
Name:PETERSON CHIROPRACTIC FAMILY WELLNESS CENTRE, S.C.
Entity Type:Organization
Organization Name:PETERSON CHIROPRACTIC FAMILY WELLNESS CENTRE, S.C.
Other - Org Name:PETERSON CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOYAL
Authorized Official - Middle Name:S
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DABC O
Authorized Official - Phone:920-834-2888
Mailing Address - Street 1:344 MCDONALD ST
Mailing Address - Street 2:
Mailing Address - City:OCONTO
Mailing Address - State:WI
Mailing Address - Zip Code:54153-1152
Mailing Address - Country:US
Mailing Address - Phone:920-834-2888
Mailing Address - Fax:920-834-4011
Practice Address - Street 1:344 MCDONALD ST
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-1152
Practice Address - Country:US
Practice Address - Phone:920-834-2888
Practice Address - Fax:920-834-4011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1530111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000075188Medicare PIN