Provider Demographics
NPI:1104200179
Name:O'FALLON, PETER JR (ATC/LAT)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:O'FALLON
Suffix:JR
Gender:M
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 DUNE LAKES CIR
Mailing Address - Street 2:B106
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-8393
Mailing Address - Country:US
Mailing Address - Phone:314-952-7123
Mailing Address - Fax:
Practice Address - Street 1:4421 COMMONS DR E
Practice Address - Street 2:SUITE-B 108
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-3484
Practice Address - Country:US
Practice Address - Phone:850-460-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-19
Last Update Date:2015-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 41452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer