Provider Demographics
NPI:1124297601
Name:CHICOINE PETERSON CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:CHICOINE PETERSON CHIROPRACTIC CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:712-276-9700
Mailing Address - Street 1:824 MORNINGSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-4801
Mailing Address - Country:US
Mailing Address - Phone:712-276-9700
Mailing Address - Fax:712-276-9409
Practice Address - Street 1:824 MORNINGSIDE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4801
Practice Address - Country:US
Practice Address - Phone:712-276-9700
Practice Address - Fax:712-276-9409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04630111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA16262OtherBCBS OF IOWA
IACP8154OtherPALMETTO GBA
IA0162628Medicaid
IACP8154OtherPALMETTO GBA
IA16262OtherBCBS OF IOWA