Provider Demographics
NPI:1609216381
Name:PETERS, BRUCE WILBERFORCE JR
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:WILBERFORCE
Last Name:PETERS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550116
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32855-0116
Mailing Address - Country:US
Mailing Address - Phone:407-347-7396
Mailing Address - Fax:
Practice Address - Street 1:823 W CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-1808
Practice Address - Country:US
Practice Address - Phone:407-347-7396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator