Provider Demographics
NPI:1427538404
Name:PETERS, BRYCE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:
Last Name:PETERS
Suffix:
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 1:9726 TOUCHTON RD STE 104
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-8305
Mailing Address - Country:US
Mailing Address - Phone:904-421-1221
Mailing Address - Fax:904-620-7996
Practice Address - Street 1:9726 TOUCHTON RD STE 104
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-8305
Practice Address - Country:US
Practice Address - Phone:904-421-1221
Practice Address - Fax:904-620-7996
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-18
Last Update Date:2018-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL52222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer