Provider Demographics
NPI:1144281684
Name:PETERSON, CARL R (DC)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:R
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 1:113 CENTRAL AVE
Mailing Address - Street 2:COON VALLEY CHIROPRACTIC
Mailing Address - City:COON VALLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54623
Mailing Address - Country:US
Mailing Address - Phone:608-452-2525
Mailing Address - Fax:608-452-2526
Practice Address - Street 1:113 CENTRAL AVE
Practice Address - Street 2:COON VALLEY CHIROPRACTIC
Practice Address - City:COON VALLEY
Practice Address - State:WI
Practice Address - Zip Code:54623
Practice Address - Country:US
Practice Address - Phone:608-452-2525
Practice Address - Fax:608-452-2526
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3132111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN263J1PEOtherBC/BS MN #
WI350041526OtherRR MEDICARE #
WI38880400Medicaid
WI0006OtherMEDICARE SEQUENCE #
WIU60662Medicare UPIN