Provider Demographics
NPI:1053159640
Name:PETERSON, MICHAEL JOHN (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5413 S SEVILLE PL
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-7572
Mailing Address - Country:US
Mailing Address - Phone:712-899-3597
Mailing Address - Fax:
Practice Address - Street 1:125 E HOLLY BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:SD
Practice Address - Zip Code:57005
Practice Address - Country:US
Practice Address - Phone:605-582-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1485111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor