Provider Demographics
NPI:1487609368
Name:RAETHER, PETER R (DC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:R
Last Name:RAETHER
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 1:1920 W 250 N STE 24
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-4774
Mailing Address - Country:US
Mailing Address - Phone:801-317-4757
Mailing Address - Fax:801-605-3439
Practice Address - Street 1:1920 W 250 N STE 24
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-4774
Practice Address - Country:US
Practice Address - Phone:801-317-4757
Practice Address - Fax:801-605-3439
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12850494-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU83336Medicare UPIN