Healthcare Provider Details

I. General information

NPI: 1669643664
Provider Name (Legal Business Name): WILLIAM RICHARD PETERSON BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 NATIONS CROSSING RD SUITE 205
CHARLOTTE NC
28217-1876
US

IV. Provider business mailing address

5000 NATIONS CROSSING RD SUITE 205
CHARLOTTE NC
28217-1876
US

V. Phone/Fax

Practice location:
  • Phone: 704-522-1020
  • Fax: 704-522-1429
Mailing address:
  • Phone: 704-522-1020
  • Fax: 704-522-1429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number549
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: