Provider Demographics
NPI:1417842360
Name:BOUC, PETER ZENITHEN
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:ZENITHEN
Last Name:BOUC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 W GRAND AVE APT 281
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-6125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 E. O'CONNOR DRIVE
Practice Address - Street 2:SUITE 105
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121
Practice Address - Country:US
Practice Address - Phone:262-723-2739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6296-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor