Provider Demographics
NPI:1922273556
Name:DAVID L PETERS
Entity Type:Organization
Organization Name:DAVID L PETERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-224-6651
Mailing Address - Street 1:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-0204
Mailing Address - Country:US
Mailing Address - Phone:989-224-6651
Mailing Address - Fax:989-224-7024
Practice Address - Street 1:611 W STATE ST
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-1468
Practice Address - Country:US
Practice Address - Phone:989-224-6651
Practice Address - Fax:989-224-7024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI002404332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0234870001Medicare NSC
MIT32695Medicare UPIN
MIA96503001Medicare PIN