Healthcare Provider Details

I. General information

NPI: 1073329850
Provider Name (Legal Business Name): BRYAN L PETERS REV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2024
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1672 MERRIMAN RD
AKRON OH
44313-9001
US

IV. Provider business mailing address

1672 MERRIMAN RD
AKRON OH
44313-9001
US

V. Phone/Fax

Practice location:
  • Phone: 330-274-7353
  • Fax:
Mailing address:
  • Phone: 330-274-7353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374K00000X
TaxonomyReligious Nonmedical Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code374T00000X
TaxonomyReligious Nonmedical Nursing Personnel
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: