Provider Demographics
NPI:1285600809
Name:PETERSEN, CLARK ALLEN (DC)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:ALLEN
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 HILLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-1941
Mailing Address - Country:US
Mailing Address - Phone:785-776-0687
Mailing Address - Fax:
Practice Address - Street 1:1419 WESTPORT LANDING PLACE SUITE 109
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502
Practice Address - Country:US
Practice Address - Phone:785-776-5778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-03705111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS23615Medicare UPIN