Provider Demographics
NPI:1962697672
Name:PETERSON CHIROPRACTIC, PC
Entity type:Organization
Organization Name:PETERSON CHIROPRACTIC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-371-6114
Mailing Address - Street 1:8702 W 124TH ST
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1828
Mailing Address - Country:US
Mailing Address - Phone:708-371-6114
Mailing Address - Fax:708-371-0816
Practice Address - Street 1:8702 W 124TH ST
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1828
Practice Address - Country:US
Practice Address - Phone:708-371-6114
Practice Address - Fax:708-371-0816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N94490OtherMEDICARE GROUP NUMBER