Provider Demographics
NPI:1962863068
Name:100 PERCENT CHIROPRACTIC PUEBLO ONE
Entity Type:Organization
Organization Name:100 PERCENT CHIROPRACTIC PUEBLO ONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:719-251-7708
Mailing Address - Street 1:1021 N MARKET PLZ
Mailing Address - Street 2:102
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-1531
Mailing Address - Country:US
Mailing Address - Phone:719-251-7708
Mailing Address - Fax:
Practice Address - Street 1:1021 N MARKET PLZ
Practice Address - Street 2:102
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-1531
Practice Address - Country:US
Practice Address - Phone:719-251-7708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0007367111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty