Provider Demographics
NPI:1871859249
Name:GARY L. PETERSON D.C.PA
Entity type:Organization
Organization Name:GARY L. PETERSON D.C.PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PETERSN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:505-883-5858
Mailing Address - Street 1:7100 MENAUL BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3688
Mailing Address - Country:US
Mailing Address - Phone:505-883-5858
Mailing Address - Fax:505-883-0010
Practice Address - Street 1:7100 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3688
Practice Address - Country:US
Practice Address - Phone:505-883-5858
Practice Address - Fax:505-883-0010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK7169Medicaid
NM2670223Medicare PIN