MEDICARE: RUBY D PETERSON

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	376J00000X	Homemaker

General Provider Information

NPI Number	:	1578227369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUBY D PETERSON

Provider Business Mailing Address
First Line	:	1646 W 45TH ST APT J353
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208
Country	:	US
Telephone Number	:	910-463-8615
Fax Number	:

Provider Business Practice Location Address
First Line	:	1646 W 45TH ST APT J353
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-6623
Country	:	US
Telephone Number	:	910-463-8615
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2021
Last Update Date	:	12/13/2021

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Directions to “ RUBY D PETERSON ” Practice Location

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