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General NPI Number Information
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NPI Number | 1275610222
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Entity Type | Organization
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Legal Business Name | COON VALLEY CHIROPRACTIC S.C.
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 113 CENTRAL AVE
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City | COON VALLEY
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State | WI
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Zip | 54623-8039
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Country | US
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Telephone | 608-452-2525
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Fax | 608-452-2526
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Provider Business Mailing Address
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Address Line | 113 CENTRAL AVE
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City | COON VALLEY
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State | WI
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Zip | 54623-8039
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Country | US
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Telephone | 608-452-2525
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Fax | 608-452-2526
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARYPAT C. PETERSON
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Credential | D.C.
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Telephone | 608-452-2525
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 3133-012
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License Number State | WI
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