Provider Demographics
NPI:1053682633
Name:PEACHERA, SRIKANTH
Entity Type:Individual
Prefix:
First Name:SRIKANTH
Middle Name:
Last Name:PEACHERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 COMMERCE AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-940-0660
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:4705 TOWNE CENTRE RD
Practice Address - Street 2:STE 101
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604
Practice Address - Country:US
Practice Address - Phone:989-401-5890
Practice Address - Fax:989-401-5892
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012227225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist