MEDICARE: PETERSON FAMILY EYECARE

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	152W00000X	Optometrist	2804	CO

General Provider Information

NPI Number	:	1568752293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETERSON FAMILY EYECARE

Provider Business Mailing Address
First Line	:	6665 DELMONICO DR
Second Line	:	STE. A
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-6801
Country	:	US
Telephone Number	:	719-599-9393
Fax Number	:

Provider Business Practice Location Address
First Line	:	6665 DELMONICO DR
Second Line	:	STE. A
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-6801
Country	:	US
Telephone Number	:	719-599-9393
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MATTHEW PETERSON
Credential	:	O.D.
Telephone Number	:	719-599-9393

Provider Enumeration Date	:	04/14/2011
Last Update Date	:	04/25/2013

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