Provider Demographics
NPI:1902391121
Name:DR. TIM PETERSON, PLLC
Entity Type:Organization
Organization Name:DR. TIM PETERSON, PLLC
Other - Org Name:PETERSON CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:WARD
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:210-691-2747
Mailing Address - Street 1:4230 GARDENDALE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3476
Mailing Address - Country:US
Mailing Address - Phone:210-691-2747
Mailing Address - Fax:210-691-2872
Practice Address - Street 1:4230 GARDENDALE ST STE 201
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3476
Practice Address - Country:US
Practice Address - Phone:210-691-2747
Practice Address - Fax:210-691-2872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7180111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1548312382OtherINDIVIDUAL NPI