Provider Demographics
NPI:1205972304
Name:PETERSON, KRISTOFOR MIKAEL (DC)
Entity type:Individual
Prefix:DR
First Name:KRISTOFOR
Middle Name:MIKAEL
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 1:1638 DELIA DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3318
Mailing Address - Country:US
Mailing Address - Phone:404-668-8719
Mailing Address - Fax:404-477-0750
Practice Address - Street 1:587 VIRGINIA AVE NE
Practice Address - Street 2:STE 4
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-3695
Practice Address - Country:US
Practice Address - Phone:404-477-7911
Practice Address - Fax:404-477-0750
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007503111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor