Provider Demographics
NPI:1962493098
Name:PETERSON, LARRY DEAN (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DEAN
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 1:6339 E. GREENWAY ROAD
Mailing Address - Street 2:#104
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-6517
Mailing Address - Country:US
Mailing Address - Phone:480-443-7678
Mailing Address - Fax:480-443-7661
Practice Address - Street 1:6339 E. GREENWAY ROAD
Practice Address - Street 2:#104
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-6517
Practice Address - Country:US
Practice Address - Phone:480-443-7678
Practice Address - Fax:480-443-7661
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1079111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor