Healthcare Provider Details

I. General information

NPI: 1548708407
Provider Name (Legal Business Name): DENISE PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2017
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 23RD ST APT 3
ROCK ISLAND IL
61201-8934
US

IV. Provider business mailing address

524 23RD ST APT 3
ROCK ISLAND IL
61201-8934
US

V. Phone/Fax

Practice location:
  • Phone: 309-433-5760
  • Fax:
Mailing address:
  • Phone: 309-433-5760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberP36216067618
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: