Provider Demographics
NPI:1568733004
Name:PETERSON DNA TESTING
Entity Type:Organization
Organization Name:PETERSON DNA TESTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEILAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-846-4577
Mailing Address - Street 1:2620 FOUNTAIN VIEW DR
Mailing Address - Street 2:117
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-7621
Mailing Address - Country:US
Mailing Address - Phone:281-846-4577
Mailing Address - Fax:
Practice Address - Street 1:2620 FOUNTAIN VIEW DR
Practice Address - Street 2:117
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-7621
Practice Address - Country:US
Practice Address - Phone:281-846-4577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory