Provider Demographics
NPI:1184789497
Name:PETERSON, LUKE HENRY (DC)
Entity type:Individual
Prefix:DR
First Name:LUKE
Middle Name:HENRY
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 1:213 S SWOOPE AVE
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5717
Mailing Address - Country:US
Mailing Address - Phone:321-972-3146
Mailing Address - Fax:
Practice Address - Street 1:213 S SWOOPE AVE
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5717
Practice Address - Country:US
Practice Address - Phone:321-972-3146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11931111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL70016OtherBCBSFL
FLU4576AMedicare ID - Type Unspecified
FLV05026Medicare UPIN