Provider Demographics
NPI:1942472303
Name:C M PETERSON LLC
Entity Type:Organization
Organization Name:C M PETERSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:702-332-8353
Mailing Address - Street 1:1328 FOX ACRES DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-0511
Mailing Address - Country:US
Mailing Address - Phone:702-332-8353
Mailing Address - Fax:702-921-6828
Practice Address - Street 1:1328 FOX ACRES DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-0511
Practice Address - Country:US
Practice Address - Phone:702-332-8353
Practice Address - Fax:702-921-6828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN000830 NV207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVQ62473Medicare UPIN