Provider Demographics
NPI:1003856816
Name:PETERSON PERFORMANCE PRODUCTS, INC.
Entity Type:Organization
Organization Name:PETERSON PERFORMANCE PRODUCTS, INC.
Other - Org Name:FOOT FITNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER, VICE PRESIDENT, SEC/TREAS
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:C PED, LMT
Authorized Official - Phone:541-617-1505
Mailing Address - Street 1:2200 NE NEFF RD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4283
Mailing Address - Country:US
Mailing Address - Phone:541-617-1505
Mailing Address - Fax:541-617-1527
Practice Address - Street 1:2200 NE NEFF RD
Practice Address - Street 2:SUITE 307
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4283
Practice Address - Country:US
Practice Address - Phone:541-617-1505
Practice Address - Fax:541-617-1527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1239650001Medicare ID - Type Unspecified