Provider Demographics
NPI:1356535694
Name:PETERSON, BRENT E (DC)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:E
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 1:1415 N 400 E
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-7539
Mailing Address - Country:US
Mailing Address - Phone:435-787-1787
Mailing Address - Fax:435-787-1797
Practice Address - Street 1:1415 N 400 E
Practice Address - Street 2:SUITE C
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7539
Practice Address - Country:US
Practice Address - Phone:435-787-1787
Practice Address - Fax:435-787-1797
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4827300-0151111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor