Provider Demographics
NPI:1609325950
Name:PETERSON, DANIEL JOHN (MBA, AT, ATC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOHN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MBA, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLIVET
Mailing Address - State:MI
Mailing Address - Zip Code:49076-9406
Mailing Address - Country:US
Mailing Address - Phone:269-749-4169
Mailing Address - Fax:
Practice Address - Street 1:320 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OLIVET
Practice Address - State:MI
Practice Address - Zip Code:49076-9406
Practice Address - Country:US
Practice Address - Phone:269-749-4169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010011772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer