Provider Demographics
NPI:1154855369
Name:GARCIA, PETER JR
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:GARCIA
Suffix:JR
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 1:5917 S TIERRA DR
Mailing Address - Street 2:
Mailing Address - City:KEARNS
Mailing Address - State:UT
Mailing Address - Zip Code:84118-6067
Mailing Address - Country:US
Mailing Address - Phone:801-440-2992
Mailing Address - Fax:
Practice Address - Street 1:5917 S TIERRA DR
Practice Address - Street 2:
Practice Address - City:KEARNS
Practice Address - State:UT
Practice Address - Zip Code:84118-6067
Practice Address - Country:US
Practice Address - Phone:801-440-2992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8394247-4202172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker