Provider Demographics
NPI:1477821783
Name:PETERSON CHIROPRACTIC CLINIC OF OSHKOSH, SC
Entity type:Organization
Organization Name:PETERSON CHIROPRACTIC CLINIC OF OSHKOSH, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-233-7744
Mailing Address - Street 1:1765 TAFT AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-3220
Mailing Address - Country:US
Mailing Address - Phone:920-233-7744
Mailing Address - Fax:
Practice Address - Street 1:1765 TAFT AVE
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-3220
Practice Address - Country:US
Practice Address - Phone:920-233-7744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1804111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1659408649Medicare UPIN