Healthcare Provider Details

I. General information

NPI: 1962697672
Provider Name (Legal Business Name): PETERSON CHIROPRACTIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8702 W 124TH ST
PALOS PARK IL
60464-1828
US

IV. Provider business mailing address

8702 W 124TH ST
PALOS PARK IL
60464-1828
US

V. Phone/Fax

Practice location:
  • Phone: 708-371-6114
  • Fax: 708-371-0816
Mailing address:
  • Phone: 708-371-6114
  • Fax: 708-371-0816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301007900
License Number StateMI

VIII. Authorized Official

Name: MARY PETERSON
Title or Position: PRESIDENT
Credential: DC
Phone: 708-371-6114