Provider Demographics
NPI:1750871174
Name:PETERS, JUSTIN DOUGLAS (LAT, ATC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DOUGLAS
Last Name:PETERS
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6130 39TH CT E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-7002
Mailing Address - Country:US
Mailing Address - Phone:941-544-8089
Mailing Address - Fax:
Practice Address - Street 1:6130 39TH CT E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-7002
Practice Address - Country:US
Practice Address - Phone:941-544-8089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer