Healthcare Provider Details

I. General information

NPI: 1437209418
Provider Name (Legal Business Name): GLEN R PETERSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 1ST ST
LA SALLE IL
61301-2416
US

IV. Provider business mailing address

PO BOX 1204
LA SALLE IL
61301-3204
US

V. Phone/Fax

Practice location:
  • Phone: 815-223-4201
  • Fax: 814-223-4210
Mailing address:
  • Phone: 815-223-4201
  • Fax: 815-223-4210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038-008373
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: