Provider Demographics
NPI:1982773867
Name:PETERSON CHIROPRACTIC CLINIC LTD
Entity type:Organization
Organization Name:PETERSON CHIROPRACTIC CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-568-1251
Mailing Address - Street 1:10135 HWY SS
Mailing Address - Street 2:
Mailing Address - City:BLOOMER
Mailing Address - State:WI
Mailing Address - Zip Code:54724
Mailing Address - Country:US
Mailing Address - Phone:715-568-1251
Mailing Address - Fax:715-568-1252
Practice Address - Street 1:10135 HWY SS
Practice Address - Street 2:
Practice Address - City:BLOOMER
Practice Address - State:WI
Practice Address - Zip Code:54724
Practice Address - Country:US
Practice Address - Phone:715-568-1251
Practice Address - Fax:715-568-1252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========010OtherBLUE CROSS