Provider Demographics
NPI:1962965855
Name:PETERSON, BLAKE (DC)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:PETERSON
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 1:1878 W 3600 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3893
Mailing Address - Country:US
Mailing Address - Phone:801-972-1222
Mailing Address - Fax:
Practice Address - Street 1:1878 W 3600 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-3893
Practice Address - Country:US
Practice Address - Phone:801-972-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10874281-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty