MEDICARE: SPRING LAKE PARK CHIROPRACTIC PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	3397	MN

General Provider Information

NPI Number	:	1003941030
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRING LAKE PARK CHIROPRACTIC PA

Provider Business Mailing Address
First Line	:	1611 COUNTY HIGHWAY 10
Second Line	:
City	:	SPRING LAKE PARK
State	:	MN
Zip	:	55432-2124
Country	:	US
Telephone Number	:	763-784-1540
Fax Number	:

Provider Business Practice Location Address
First Line	:	1611 COUNTY HIGHWAY 10
Second Line	:
City	:	SPRING LAKE PARK
State	:	MN
Zip	:	55432-2124
Country	:	US
Telephone Number	:	763-784-1540
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAVID DONALD PETERSON
Credential	:	D.C.
Telephone Number	:	763-784-1540

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	08/22/2020

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