MEDICARE: DR. NICHOLAUS PETTERSON D.C.

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	14730	TX

General Provider Information

NPI Number	:	1669056628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLAUS PETTERSON D.C.

Provider Business Mailing Address
First Line	:	1007 W MITCHELL ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76013-2508
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1007 W MITCHELL ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76013-2508
Country	:	US
Telephone Number	:	817-460-9000
Fax Number	:

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

Provider Enumeration Date	:	05/06/2021
Last Update Date	:	05/06/2021

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