Provider Demographics
NPI:1053399295
Name:MAGNIFICO, PETER (DC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:MAGNIFICO
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 1:1112 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:64067-1336
Mailing Address - Country:US
Mailing Address - Phone:660-259-3121
Mailing Address - Fax:
Practice Address - Street 1:1112 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MO
Practice Address - Zip Code:64067-1336
Practice Address - Country:US
Practice Address - Phone:660-259-3121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004931111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0006339Medicare ID - Type Unspecified