Provider Demographics
NPI:1801938444
Name:PETERS, REYNE JEAN (DC)
Entity type:Individual
Prefix:
First Name:REYNE
Middle Name:JEAN
Last Name:PETERS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216-1006
Mailing Address - Country:US
Mailing Address - Phone:920-388-0285
Mailing Address - Fax:920-388-0291
Practice Address - Street 1:224 ELLIS ST
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-1006
Practice Address - Country:US
Practice Address - Phone:920-388-0285
Practice Address - Fax:920-388-0291
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3480111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU69757Medicare UPIN
WI35569Medicare ID - Type Unspecified