Provider Demographics
NPI:1831366442
Name:SYLVETTE G PETERSON
Entity type:Organization
Organization Name:SYLVETTE G PETERSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SYLVETTE
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM, CPED
Authorized Official - Phone:787-882-4280
Mailing Address - Street 1:CARR 107 KM 3.6 BO BORINQUEN
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00604
Mailing Address - Country:US
Mailing Address - Phone:787-882-4280
Mailing Address - Fax:787-882-4280
Practice Address - Street 1:CARR 107 KM 3.6 BO BORINQUEN
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00604-0717
Practice Address - Country:US
Practice Address - Phone:787-882-4280
Practice Address - Fax:787-882-4280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0927710001Medicare NSC