Provider Demographics
NPI:1407254436
Name:FOREST PARK PETERS CO, LLC
Entity Type:Organization
Organization Name:FOREST PARK PETERS CO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:B ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-315-6432
Mailing Address - Street 1:6730 BRADBURY LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2836
Mailing Address - Country:US
Mailing Address - Phone:214-315-6432
Mailing Address - Fax:214-317-4667
Practice Address - Street 1:6125 LUTHER LN
Practice Address - Street 2:#175
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-6202
Practice Address - Country:US
Practice Address - Phone:214-315-6432
Practice Address - Fax:214-317-4667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical TechnologistGroup - Single Specialty