Provider Demographics
NPI:1194749333
Name:PETERSON, SHANE C (DC)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:C
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2303 SCHNEIDER AVE SE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-7005
Mailing Address - Country:US
Mailing Address - Phone:715-233-1867
Mailing Address - Fax:715-233-1868
Practice Address - Street 1:2303 SCHNEIDER AVE SE
Practice Address - Street 2:SUITE 150
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-7005
Practice Address - Country:US
Practice Address - Phone:715-233-1867
Practice Address - Fax:715-233-1868
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3763111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor