Provider Demographics
NPI:1194854372
Name:PETERSON PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PETERSON PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:402-390-1027
Mailing Address - Street 1:7205 W CENTER RD
Mailing Address - Street 2:STE 101
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2380
Mailing Address - Country:US
Mailing Address - Phone:402-390-1027
Mailing Address - Fax:402-390-1037
Practice Address - Street 1:7205 W CENTER RD
Practice Address - Street 2:STE 101
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2380
Practice Address - Country:US
Practice Address - Phone:402-390-1027
Practice Address - Fax:402-390-1037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025195100Medicaid
NE099645Medicare ID - Type Unspecified