MEDICARE: FOREST PARK PETERS CO, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZS0410X	Surgical Technologist

General Provider Information

NPI Number	:	1407254436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOREST PARK PETERS CO, LLC

Provider Business Mailing Address
First Line	:	6730 BRADBURY LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-2836
Country	:	US
Telephone Number	:	214-315-6432
Fax Number	:	214-317-4667

Provider Business Practice Location Address
First Line	:	6125 LUTHER LN
Second Line	:	#175
City	:	DALLAS
State	:	TX
Zip	:	75225-6202
Country	:	US
Telephone Number	:	214-315-6432
Fax Number	:	214-317-4667

Authorized Official
Title or Position	:	OWNER
Name	:	B ROBERT PETERS
Credential	:	MD
Telephone Number	:	214-315-6432

Provider Enumeration Date	:	12/08/2014
Last Update Date	:	12/08/2014

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