MEDICARE: DR. DONALD ALBERT PETERSON DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	5463	CO

General Provider Information

NPI Number	:	1104821362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONALD ALBERT PETERSON DC

Provider Business Mailing Address
First Line	:	835 HIGHWAY 105
Second Line	:	SUITE A
City	:	PALMER LAKE
State	:	CO
Zip	:	80133-9069
Country	:	US
Telephone Number	:	719-332-6201
Fax Number	:

Provider Business Practice Location Address
First Line	:	835 HIGHWAY 105
Second Line	:	SUITE A
City	:	PALMER LAKE
State	:	CO
Zip	:	80133-9069
Country	:	US
Telephone Number	:	719-332-6201
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	05/11/2012

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