Healthcare Provider Details

I. General information

NPI: 1831835958
Provider Name (Legal Business Name): LUKE CHARLES PETERSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 BOARDMAN CANFIELD RD
BOARDMAN OH
44512-4010
US

IV. Provider business mailing address

1265 BOARDMAN CANFIELD RD
BOARDMAN OH
44512-4010
US

V. Phone/Fax

Practice location:
  • Phone: 330-758-9400
  • Fax: 330-726-8676
Mailing address:
  • Phone: 330-758-9400
  • Fax: 330-726-8676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT019817
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: