Healthcare Provider Details

I. General information

NPI: 1083687636
Provider Name (Legal Business Name): CHARLES J PETERSON DC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 W SHERIDAN AVE
SHENANDOAH IA
51601
US

IV. Provider business mailing address

1203 W SHERIDAN AVE
SHENANDOAH IA
51601
US

V. Phone/Fax

Practice location:
  • Phone: 712-246-4798
  • Fax: 712-246-5613
Mailing address:
  • Phone: 712-246-4798
  • Fax: 712-246-5613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number04065
License Number StateIA

VIII. Authorized Official

Name: CHARLES J PETERSON
Title or Position: PRESIDENT
Credential: DC
Phone: 712-246-4798