Healthcare Provider Details

I. General information

NPI: 1649216235
Provider Name (Legal Business Name): GARRICK KEVIN PETERSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 S MIRAGE AVE
LINDSAY CA
93247-2541
US

IV. Provider business mailing address

PO BOX 928
LINDSAY CA
93247-0928
US

V. Phone/Fax

Practice location:
  • Phone: 559-562-4963
  • Fax: 559-562-1333
Mailing address:
  • Phone: 559-562-4963
  • Fax: 559-562-1333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number9157T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: