Healthcare Provider Details

I. General information

NPI: 1649185521
Provider Name (Legal Business Name): ETHAN PETERSON CHIROPRACTIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 W GRACE ST
CHICAGO IL
60613-2805
US

IV. Provider business mailing address

1024 STONERIDGE DR
LAWRENCE KS
66049-4771
US

V. Phone/Fax

Practice location:
  • Phone: 785-979-0690
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. ETHAN E PETERSON
Title or Position: OWNER
Credential: DC
Phone: 785-979-0690