Provider Demographics
NPI:1790185262
Name:PETERS, WILLIAM III
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:PETERS
Suffix:III
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:BILLY
Other - Middle Name:
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:344 E 100 S STE 301
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1727
Mailing Address - Country:US
Mailing Address - Phone:801-428-3418
Mailing Address - Fax:
Practice Address - Street 1:880 E 3375 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1536
Practice Address - Country:US
Practice Address - Phone:801-708-3418
Practice Address - Fax:801-708-7004
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker