Provider Demographics
NPI:1336215896
Name:PETERSON FAMILY CHIROPRACTIC AND WELLNESS CENTER
Entity Type:Organization
Organization Name:PETERSON FAMILY CHIROPRACTIC AND WELLNESS CENTER
Other - Org Name:PETERSON CHIROPRACTIC AND ACUPUNCTURE
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:573-426-3418
Mailing Address - Street 1:1205 HAUCK DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-4900
Mailing Address - Country:US
Mailing Address - Phone:573-426-2225
Mailing Address - Fax:573-426-2290
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000013901Medicare ID - Type Unspecified