Provider Demographics
NPI:1730257825
Name:PETERSEN, CLAIRE NILES (DC)
Entity type:Individual
Prefix:DR
First Name:CLAIRE
Middle Name:NILES
Last Name:PETERSEN
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:N236 DANBURY DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-4565
Mailing Address - Country:US
Mailing Address - Phone:920-261-1044
Mailing Address - Fax:920-261-1435
Practice Address - Street 1:612 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-2111
Practice Address - Country:US
Practice Address - Phone:920-261-1226
Practice Address - Fax:920-261-1435
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1330-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391281394018OtherB C
WI391281394018OtherB C
WI75-465Medicare ID - Type Unspecified