Provider Demographics
NPI:1972679439
Name:PETERSON, KEITH A (DC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
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 1:12661 COUNTY ROAD 5050
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-8053
Mailing Address - Country:US
Mailing Address - Phone:573-578-6416
Mailing Address - Fax:
Practice Address - Street 1:1205 HAUCK DR
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4900
Practice Address - Country:US
Practice Address - Phone:573-426-2225
Practice Address - Fax:573-426-2290
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003008892111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO176200OtherBLUE CROSS BLUE SHIELD
MO694831OtherHEALTHLINK
MO002013901Medicare ID - Type UnspecifiedMEDICARE
MO176200OtherBLUE CROSS BLUE SHIELD