Provider Demographics
NPI:1568758282
Name:PETERSON PERFORMANCE PRODUCTS INC
Entity Type:Organization
Organization Name:PETERSON PERFORMANCE PRODUCTS INC
Other - Org Name:PETERSON'S ORTHOTIC LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:C PED, C O
Authorized Official - Phone:541-647-1108
Mailing Address - Street 1:900 SE WILSON AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1416
Mailing Address - Country:US
Mailing Address - Phone:541-647-1108
Mailing Address - Fax:541-647-2162
Practice Address - Street 1:900 SE WILSON AVE
Practice Address - Street 2:SUITE F
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1416
Practice Address - Country:US
Practice Address - Phone:541-647-1108
Practice Address - Fax:541-647-2162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC15236332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment