Provider Demographics
NPI:1669480968
Name:PETERSON PT LLC
Entity Type:Organization
Organization Name:PETERSON PT LLC
Other - Org Name:PETERSON PHYSICAL THERAPY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BREK
Authorized Official - Middle Name:LAMONT
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:928-771-2977
Mailing Address - Street 1:1320 W IRON SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1414
Mailing Address - Country:US
Mailing Address - Phone:928-771-2977
Mailing Address - Fax:928-771-2987
Practice Address - Street 1:1320 W IRON SPRINGS RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1414
Practice Address - Country:US
Practice Address - Phone:928-771-2977
Practice Address - Fax:928-771-2987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ50792080S0010X
AZ58102080S0010X
AZ64992080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00468Medicare UPIN
AZZ64026Medicare UPIN