Healthcare Provider Details

I. General information

NPI: 1356159842
Provider Name (Legal Business Name): CHET PETERSON RN, CCM, CDCES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2024
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 RUSSELL ST
CRAIG CO
81625-2019
US

IV. Provider business mailing address

745 RUSSELL ST
CRAIG CO
81625-2019
US

V. Phone/Fax

Practice location:
  • Phone: 970-824-8233
  • Fax: 970-870-1326
Mailing address:
  • Phone: 970-824-8233
  • Fax: 970-870-1326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number4241846
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number32305508
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.1629651
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: