Healthcare Provider Details

I. General information

NPI: 1336619626
Provider Name (Legal Business Name): PETERSON HOLISTIC SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6989 UNIVERSITY AVE
WINDSOR HEIGHTS IA
50324-1540
US

IV. Provider business mailing address

170 EVERGREEN DR APT 200C
WAUKEE IA
50263-8724
US

V. Phone/Fax

Practice location:
  • Phone: 515-829-9277
  • Fax:
Mailing address:
  • Phone: 515-829-9477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: KEVIN JAMES PETERSON
Title or Position: OWNER / HOLISTIC HEALTH COACH
Credential: LMT, CPT, HHC
Phone: 515-829-9477