Provider Demographics
NPI:1366833865
Name:PETERSON, BRANDY (ABOC, NCLE)
Entity Type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ABOC, NCLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18511 SOUTH RIVER RD,
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18511 SOUTH RIVER RD,
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093
Practice Address - Country:US
Practice Address - Phone:734-657-7543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI156379156FC0801X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter