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General NPI Number Information
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NPI Number | 1003120452
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Entity Type | Organization
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Legal Business Name | KIMBERLY PETERSON, O.D., INC.
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Dates
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Enumeration Date | 07/27/2010
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Last Update Date | 07/27/2010
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Provider Practice Location Address
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Address Line | 1850 N RIVERSIDE AVE SUITE 100
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City | RIALTO
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State | CA
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Zip | 92376-8071
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Country | US
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Telephone | 909-421-3030
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Fax | 909-421-3059
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Provider Business Mailing Address
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Address Line | 1850 N RIVERSIDE AVE SUITE 100
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City | RIALTO
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State | CA
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Zip | 92376-8071
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Country | US
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Telephone | 909-421-3030
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Fax | 909-421-3059
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Authorized Official
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Title or Position | OWNER
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Name | DR. KIMBERLY PETERSON
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Credential | O.D.
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Telephone | 909-421-3030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 11094T
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License Number State | CA
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