Healthcare Provider Details

I. General information

NPI: 1124843958
Provider Name (Legal Business Name): KEVIN MICHAEL PETERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4705 S APOPKA VINELAND RD STE 100
ORLANDO FL
32819-3151
US

IV. Provider business mailing address

5114 INDIALANTIC DR
ORLANDO FL
32808-4508
US

V. Phone/Fax

Practice location:
  • Phone: 407-905-9300
  • Fax:
Mailing address:
  • Phone: 407-405-4664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License NumberOT14149
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: