Provider Demographics
NPI:1942619713
Name:PETERSEN, REESE RAYMOND (DC)
Entity Type:Individual
Prefix:DR
First Name:REESE
Middle Name:RAYMOND
Last Name:PETERSEN
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 1:2418 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-6827
Mailing Address - Country:US
Mailing Address - Phone:563-259-6173
Mailing Address - Fax:
Practice Address - Street 1:2418 S 18TH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-6827
Practice Address - Country:US
Practice Address - Phone:563-259-6173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA074678111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IB3196001Medicare PIN